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HomeMy WebLinkAboutBoleslaus • OFFICE OF THE TOWN CLERK ' •COFQ(K ' Town of Southold - COG Judith T. Terry, Town Clerk Town Hall, 53095 Main Road r n r P. O. Box 1179 cn :Z"} ___ �"M • Southold, New York 11971 4 " *-$moo! - �,ap�-.• Telephone (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 25- (Q Residential xx Non-Residential Fee $ 10.00 Septic Cesspool Xx NAME OF OWNER: Boleslaus and Theresa Kutz OWNER MAILING ADDRESS: Box 371 Laurel, New York 11948 OWNER PROPERTY ADDRESS: 6780 Peconic Bay Blvd. Laurel, New York OWNER TELEPHONE NUMBER: 516-298-5849 TAX MAP NO. : Section 126 Block 11 Lot 5 CROSS STREET: Bray Avenue TYPE OF SYSTEM: Septic Tank New _ Existing Cesspool XX New Existing Xx Residential xx Non-Residential DATE OF PREVIOUS PUMP-OUT: Unknown • 40*IrelL'ut1111-1 Southold Town Cftrk DATE: August 22, 1986 (TOWN'] SEAL) / .. ,„„ OFFICE OF THE TOWN CLERK ,C�FFO Town of Southold 0���. 4.v� CQ�': Application No. �6 Judith T. Terry, Town Clerk 44 ".<:6) Town Hall, 53095 Main Road ' ',. Residential P. O. Box 1179 U' °: x ,. Non-Residential Southold, New York 11971 O ® - ' �.`� Telephone 4#0.0 .��� �• (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION r for __11 1,-0-v, e-sa ec S OPERATION PERMIT U -r ^ (c-. C S-e-e. SEPTIC TANK or CESSPOOL Operation Permit No. (27 cirro:12. Ofe:Al Fee 1 0 > ' _ e¢iv i©°e4i" Al e9-ejit --, DATE 7/;1 3/84D 1 Ifo --1C-S-- OWNER NAME: EDLESLtv5 v i 9- -1k-kERESR 'K.vi Z OWNER MAILING ADDRESS: (01 b D c)e-(,pN1«., Rcy ( — v Ib ( oic' )21 t--PwR L (.y- It9t6, e OWNER PROPERTY ADDRESS: OWNER TELEPHONE NUMBER: a9 8 - J s q 7 , ,.___ TAX MAP NO. : Section l p� (D Block I ( Lot CROSS STREET: CR ( (kV t TYPE OF SYSTEM: Septic Tank New Existing Cesspool 17 New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: Ui\➢i,(NOWIli LOCATION MAP: Must be attached hereto before permit may be issued. (Locate building and system; give north arrow and feet PG coNt �6qf d1 staace, approximately, to building and closest road.) 1-ho m-. 4-0 e,..C—45 POOL l00 6-k-. -----r(Niti--Q -.1.-- e-OL-s Signature of Applicant ) 12EsiDe c RECEIVED BY: 0 e Town Cl rk's O l ice DATE: atv ° . /l i