HomeMy WebLinkAboutKujawski (2) f
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f Town Hall, 53095 Main Road
,4 P.O. Box 1179
„4-� 1\ �1i1 i°' Southold, New York 11971
JUDITH T.TERRY �,„ �r.'i FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1483-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KUJAWSKI, BENJAMIN
Mailing Address 1 BAY AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 BAY AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6792
Tax Map No. section 97.00 block 9 lot 9.000
Cross Street LESLIE ROAD
Date Of Last Pump Out 0/00/82
Issue Date: 6/14/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK l'AWFt7L-
Town of Southold C0 Application No. e n3
Judith T. Terry, Town Clerk _t1t ' ;!!!'A
}. .•C I $10.00 — Residential
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Town Hall, 53095 Main Road �r4 -
p. O. Box 1179 u.3 ` '`t== �` $25.00 - Non-Residential
Southold, New York 11971 Oi
Telephone _0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
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Operation Permit No.
Fee $ /t
_
DATE , /� — re
'OWNER NAME: /2.e4/ -2-24,, e,) •
OWNER MAILING ADDR
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OWNER PROPERTY_.ADDRESS:
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section C7 7 Block Lot
CROSS STREET: ,ee,P)-e-C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool //� New Existing
Residential � Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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 pplicant
IQ� M
RECEIVED BY:
Town Clerk's Office
DATE: 6 / j G
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