HomeMy WebLinkAboutGristina .004m/re;
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Town Hall, 53095 Main Road
� 1 P.O. Box 1179
��O°� 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. 93-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner GRISTINA, JERMONE
Mailing Address 1 26 GLEN EAGLES DRIVE
Mailing Address 2
City St Zip LARCHMONT NY 10538-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-834-5220
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: 7/31/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .c0FC1,� '
Town of Southold , • Qs:- , Application No../c'i
Judith T. Terry, Town Clerk . &Ai;
� , y
Town Hall, 53095 Main Road
'� Residential
p. O. Box 1179 cn t47.7r ei ; Non-Residential
Southold, New York 11971
Telephone �.� * l►•11,�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ aS`
• DATE 0in(87
OWNER NAME: g 8/5 %/a.4 Je,coM E'
OWNER MAILING ADDRESS: 2‘ GL&iJ E4CL..R5 O/
LARCH/11 o,J r, rv'-y /0,6-3 r'
OWNER PROPERTY ADDRESS: ,A4/-//L /-O .
COC' oGi tyy /0,3 s
OWNER TELEPHONE NUMBER: 5/1/ -- F!3
TAX MAP NO. : Section /09100 Block / Lot / 3, 700
CROSS STREET: 14-LVA/Y.S. LkNL�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New X Existing
Residential Non-Residential X
DATE OF ;PREVIOUS' PUMP-OUT: -11491"..e_ =
LOCATION MAP: Must be attached hereto before permit may be issued.
(Loca-tiq building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of r pplicant
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3s
"L5
RECEIVED BY:
Town O(erk's 0 ce
DATE:
J$L 31 1969
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