HomeMy WebLinkAboutPelligrino, Frank „ ,,/iii,
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ELIZABETH A. NEVILLE ��_ 'yd\ Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
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REGISTRAOF VITAL STATISTICS ` � Fax (631) 765-6145
MARRIAGE OFFICER �. 4 �1
RECORDS MANAGEMENT OFFICER � Q! 40/ Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER gos,lip”
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4030-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner PELLEGRINO, FRANK & BARBARA
Mailing Address 1 165 LAWRENCE AVENUE
Mailing. Address 2
City St Zip HAUPPAUGE NY 11788-0000
Property Address 1 3300 MINNEHAHA BLVD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-366-6033
Tax Map No. section 87.00 block 3 lot 38.000
Cross Street OWAISSA AVENUE
Issue Date: 6/21/00 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK OcjVFFOUr`+O:
TOWN OF SOUTHOLD �. _\ Application No. 3d
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4/64/6ELIZABETH A.NEVILLE,TOWN CLERK � $10.00 - Residential (/
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 �'; $25.00 - Non-Residential
Telephone 4c lit I" �'
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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uAPPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /D,00
k-Ooo DATE (p/7
OWNER NAME: Fi'a.,v.. it4a z 17�/l top
OWNER MAILING ADDRESS: X65" LQc J/'p1ic..e
J 1ofa„.1 e 7 1179$
OWNER PROPERTY ADDRESS: 3300 /1/I i an a b►& h4... E
SQ)Tholc( , N y t 1.7I
OWNER TELEPHONE NUMBER: - 346.-63
TAX MAP NO. : Section 67.o0 Block 3 Lot 39,00
CROSS STREET: PL.,/ ct:!s s a__ 4 ue4J x...
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing i/
Residential V Non-Residential
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.)
Ze..40-4-1
Signat re of A icant
RECEIVED BY:
Town Clerk's Office
DATE:
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- Y SM. . LIC. NO. 49618
ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION P C. V '. ,- -, '• .. ,
OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW
EXCEPT AS PER SECTION 7209—SUBDIVISION 2. ALL CERTIFICATIONS (516) `;.' tr4`
HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF ONLY IF P. 0. 8• •10°
SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYOR 1230 TRAVELER STREET
WHOSE SIGNATURE APPEARS HEREON. SOUTHOLD, N. Y. 11971
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