HomeMy WebLinkAboutGrohoski (2) OWsw
Town Hall, 53095 Main Road
$0 P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ��'' d, l�� 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. 325-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner GROHOSKI , IRENE A.
Mailing Address 1 P.O. BOX 44
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 DEPOT LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6935
Tax Map No. section 96. 00 block 5 lot 4. 001
Cross Street C.R. 48
Date Of Last Pump Out 5/14/87
Issue Date: 7/14/87 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Towti of Southold ���� �OC�Ij
Judith T. Terry, Town Clerk ��
Town Hall, 53095 Main Road h,
P. O. Box 1179 v'
Southold, New York 11971 \ .YQ ® -"
Telephone --:r1- 0/ 110`
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 325 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Irene A. Grohoski
OWNER MAILING ADDRESS: Box 44
Cutchbque; New York 11935
OWNER PROPERTY ADDRESS: Depot Lane
Cutchogue, New York
OWNER TELEPHONE NUMBER: 516-734-6935
TAX MAP NO. : Section 96 Block 5 Lot 4,1
CROSS STREET: C. R. 48
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: May 14, 1987
Judith T. Terry
Southold Town Clerk
DATE: July 14, 1987 •
(TOWN* _SEAL)
OFFICE OF THE TOWN CLERK COMA'
Town of Southold �� CQ ',, Application N
Judith T. Terry, Town Clerkp
Town Hall, 53095 Main Road � 's : Residential
P. O. Box 1179 cr3 ;..W; Non-Residential
Southold, New York 11971
Telephone •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /b
DATE 7 — ( k /
OWNER NAME: •
OWNER MAILING ADDRESS: 7 P,7X
0`-erel
OWNER PROPERTY ADDRESS: (7/7/10_17 0 q u //%
OWNER TELEPHONE NUMBER: 7�ZL j `t S`
TAX MAP NO. : Section Bloc 1C f/ Lot
CROSS STREET: e 4IX
TYPE OF SYSTEM: Septic Tank New Existing X
Cesspool X New Existing X
Residential y' 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.)
4 !
IA J , �
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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