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JUDITH T. TERRY zTown Hall, 53095 Main Road
TOWN CLERK ® r� • P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS s Southold, New York 11971
MARRIAGE OFFICER � ® Fax Fax (516) 765-1823
��i® a� i�� Telephone (516) 765-1801
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SOUTHOLD WASTEWAT '": POSAL PERMIT
OPERATION PERMIT -
suCTWEICKNIRFoXIIES ION5IN CLERK
TOWN OF SOUTHOLD
Operation Permit No. 3026-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GRABOWSKI, VICTOR
Mailing Address 1 P. O. BOX 132
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 18875 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-734-6594
Tax Map No. section 108.00 block 4 lot 2.000
Cross Street CARDINAL DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 5/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .SVFFO(e =
Town of Southold 0�� ,,.,, CQG' , Application No.j 0 6,
Judith T. Terry, Town Clerk S,it, es: -
Town' Hall, 53095 Main Road = }'; : 1 $10.00 - Residential
P. O. Box 1179 u7 ; f2 ► �` $25.00 - Non-Residential
Southold, New York 11971 O ort; • '$
Telephone
Telephone 640 Alt 0 .6
(516) 765-1801
TOWN OF SOUTHOLD.
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
RECEIVED
OPERATION PERMIT
MAY 1.7 1993
SEPTIC TANK or CESSPOOL
Southold Town Clerk
Operation Permit No. ;
Fee $
' DATE
OWNER NAME: V) ' C fe 4 4 6 teiSwi
OWNER MAILING ADDRESS:
_ _ OWNER- PROPERTY ADDRESS-:- - ;_ -. - • _
OWNER TELEPHONE NUMBER: 73 V t o f5 ,
j TAX MAP NO. : Section /00 Block V Lot
CROSS STREET: C fDe b/4/,4 1 OktiPZ. gl A7�/ ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ew � Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
0 .
',.iiiiMIP ../ 7.44/ 4/ft--::'
- Sigma'ure of Applicant
illie
RECEIVED BY: , •
Town lerk's ffice '
---- DATE:
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