HomeMy WebLinkAboutKujawski OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road c ` '
P. 0. Box 1179
Southold, New York 11971 ® 0�-
Telephone ®d ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 140== Residential X
Fee $ 10.00 Non-Residential
Septic X Cesspool X
NAME OF OWNER: Frank A. Kuiawski Jr.
OWNER MAILING ADDRESS: P.O. Box 727
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: 1300 Marratooka Road
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-9146
TAX MAP NO. : Section 115 Block 9 Lot 1.2
CROSS STREET: New Suffolk Avenue
TYPE OF SYST-EM: Septic Tank X New Existing X
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: August 1986
Judith T. Terry
Southold Town Clerk
DATE: November 13, 1986
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold �� CQG Application No,/�/o
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road Residential
P. 0. Box 1179 cn 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 2. �►�
OWNER NAME: ,q-^/`� �Vdu` e
OWNER MAILING ADDRESS: y
OWNER-PROPERTY ADDRESS: / o o
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section / Block / Lot -J.-
CROSS
CROSS STREET: NP•w ���
TYPE OF SYSTEM: Septic Tank ✓ New Existing
Cesspool I/ New i Existing ✓
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: f�gfep
LOCATION MAP: Must be attached hereto before pe mit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signatu e of/Applicant
RECEIVED BY:
Town lerk's Office
DATE:
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