HomeMy WebLinkAboutKruse OFFICE OF THE TOWN CLERK FD
Town of Southold
Judith T. Terry, Town Clerk r'
Town Hall, 53095 Main Road
P. 0. Box 1179 yr.
Southold, New York 11971 �-
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Telephone �1t
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 289 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X ;
NAME OF OWNER: Wilfred G. Kruse
OWNER MAILING ADDRESS: Lilac Lane
Cutchoque New York 11935
OWNER PROPERTY ADDRESS: Lilac Lane
Cutchoque New York
OWNER TELEPHONE NUMBER: 734-6510
TAX MAP NO. : Section 104 Block 1 Lot 24
CROSS STREET: Sterling Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing _
Residential X Non-Residential
DATE OF .PREVIOUS PUMP-OUT: Unknown
Judith T. Terry
Southold Town Clerk
DATE: April 28, 1987
(TOWN SEAL)
OFFICtE OF THE TOWN CLERK
Town of Southold ��� �QG Application No.
Judith T. Terry, Town Clerk Z
Town Hall, 53095 Main Road c : Residential
P. 0. Box 1179 Ln Non-Residential
Southold, New York 11971 O
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
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OWNER NAME: �
OWNER MAILING ADDRESS:
OWNER- PROPERTY ADDRESS:
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OWNER TELEPHONE NUMBER:'
TAX MAP NO. : Section /® Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New. Existing
Residential /\ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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