HomeMy WebLinkAboutKujawski (3) Town Hall, 53095 Main Road
P.O. Box 1179
®� Southold, New York 11971
JUDITH T.TERRY 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. 1131-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KUJAWSKI, RAYMOND
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Mailing Address 1 BOX 307
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Mailing Address 2
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City St Zip LAUREL NY 11948-0000
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Property Address 1 A,LDRICH LANE
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Property Address 2
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City St Zip LAUREL NY 11948-0000
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Owner Telephone No. 516-298-9484
Tax Map No. section 120.00 block 3 lot 13.000
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Cross Street SOUND AVENUE
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Date Of Last Pump Out 0/00/00
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Issue Date: 6/01/89 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�VFFI
Town of Southold �® CQG Application No.��3
Judith T. Terry, Town Clerk
Residential
Town Hall, 53095 Main Road 7
P. 0. Box 1179 cr2 Non-Residential
Southold, New York 11971 O
Telephone ®� �►���
(516) 765-1801
RKEND TOWN OF SOUTHOLD
MAY 22 1909 SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Tom vadi MUM
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation
Permit No.
Fee $
DATE
OWNER NAME: GSI I P` L4~ JS'C ~
OWNER MAILING ADDRESS: /),�lny e!�x
• ��9 Cl r�7 ��A. �/�'sig
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
j TAX MAP NO. : Section �o�—C) Block Lot
CROSS STREET: Lie
TYPE OF SYSTEM: Septic Tank p / New Existing
Cesspool V New Existing
Residential [/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: �2y� /,
LOCATION MAP: Must be attached hereto before permit maybe issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
4_
gnatuYe of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
II `�1 '' '
09
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