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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK r tgm r • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ;
4, Fax (516) 765-1823
� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 123-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner GRISTINA, JERRY AND CAROL
Mailing Address 1 P. O. BOX 1009
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 GRISTINA VINEYARD
Property Address 2 MAIN ROAD
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7089
Tax Map No. section 109.00 block 1 lot 13.000
Cross Street ALVAHS LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/02/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK
Town of Southold � CQG• , Application No./p23
Judith T. Terry, Town Clerk .� { fi vy
Town Hall, 53095 Main Road zr. � _ -4 $10.00 - Residential
P. O. Box 1179 crs `- y` ,�• $25.00 Non-Residential V
Southold, New York 11971 O1516144":"0- ,
Telephone :
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 'Sirs-O
DATE /;3/��
OWNER NAME: Tao' D 6416770 ( / 716 V1il6Y
OWNER MAILING ADDRESS: ,0 iOX f009
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OWNER PROPERTY ADDRESS: pipir 6G 75.
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OWNER TELEPHONE NUMBER: 734-70
TAX MAP NO. : Section /000 (foci Block ! Lot P(.0 13
CROSS STREET: Al 5 t
TYPE OF SYSTEM: Septic Tank 2, New Existing V
"" Cesspool New Existing (."
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: g/a3/Q/
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.)
71.3ata.. '
Signature o Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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MAIN ROD - F.O. BO 1oo0
CUtCHO UE, .Y. 11935
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