HomeMy WebLinkAboutGrohoski ,LLQ 1
B ` , , 4 P Town Hall, 53095 Main Road
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?, ' �,�: P.O. Box 1179
.-. , o'`�®ply! Southold, New York 11971
JUDITH T.TERRY = �/1 $00.i TELEPHONE
TOWN CLERK (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. 877-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GROHOSKI, EDWARD
Mailing Address 1 P. O. BOX 627
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 BUNGALOW LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9649
Tax Map No. section 123.00 block 2 lot 15.001
Cross Street CENTER STREET
Date Of Last Pump Out 0/00/00
Issue Date: 10/06/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
JO' ire „ � Iri
OFFICE OF THE TOWN CLERK C��F�U( —`
Town of Southold �� , CQ Application No.
Judith T. Terry, Town Clerk
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Town Hall, 53095 Main Road iv:- " '� Residential
P. O. Box 1179 cr) " p=?r: ► ;' Non-Residential
Southold, New York 11971 OS : z ••`
Telephone = 1
(516) 765-1801
TOWN OF SOUTHOLD
AUG 011989 SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Tows Ma Dam APPLICATION
tor
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
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OWNER NAME:
OWNER MAILING ADDRESS: c>
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OWNER PROPERTY ADDRESS: se��y /u/
OWNER TELEPHONE NUMBER: — C /
TAX MAP NO. : Section /03-z-A-11thilck Lot
CROSS STREET: . =t /
TYPE OF SYSTEM: Septic .Tank New,., Existing
Cesspool New ' Existing
Residential v 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 roach)
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Sig atu• atof pplica
RECEIVED BY: g _
R Citni ownC rk's O f ce
DATE: i_;u1 0 6 iB8U
Town Clerk Southold
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