HomeMy WebLinkAboutGradowski 11°1 If ait
V Town Hall, 53095 Main Road
�® .,1� P.O. Box 1179
_�® `���•,•'• Southold, New York 11971
JUDITH T.TERRY "�ii,"04 Air ��/ 765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1503-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GRADOWSKI, JOSEPH S.
Mailing Address 1 WELLS AVENUE, BOX 511
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 3675 WELLS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3355
Tax Map No. section 70.00 block 4 lot 4.000
Cross Street OAKLAWN AVENUE
Date Of Last Pump Out 0/00/74
Issue Date: 7/25/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
!Y.
o .,
OFFICE OF THE TOWN CLERK c�VFFO(,r
Town of Southold Qy^M1 {, ,�4. -• Application No. /6703
Judith T. Terry, Town Clerk i.', ,yam �►`
Town Hall, 53095 Main Road ='`°;t_t --A_.- ‘‘i $10.00 - Residential
P. O. Box 1179tor- " '�',w� `
: :.:_.sx 1 $25.00 - Non-Residential
Southold, New York 11971 Obit rs' �0 ��`�
Telephone *Q1 214‘;''.
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(516) 765-1801 ,•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT '
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE �Ul.y _'3 , V 5 J
OWNER NAME: escp5c-PM S Q adds/C1 '
•
•
OWNER MAILING ADDRESS: lb, "1.-1.-C Ove, j "Ea-x ..S./ 1
So v T/-fb Lb . .,u I ' HO/
OWNER PROPERTY ADDRESS : 30-e V4L1,5. r)vc •
Soo ri-aL-
OWNER TELEPHONE NUMBER: 965-' 3 .1'-"
TAX MAP NO. : Section 20 Block Lot
CROSS STREET: 0 L-AW„/ 4vi '
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ')S New Existing X
Residential )c Non-Residential
DATE OF PREVIOUS PUMP-OUT: f f f (1,).5) 9 J
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.)
!moi i.F}417 A4
r f Signature of Applicant
f
RECEIVED BY: ;
Town Clerk's Office
DATE:
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