HomeMy WebLinkAboutGrzesik JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® 2C • P.O. Box 1179
td'' Southold, New York 11971
REGISTRAR OF VITAL STATISTICS = V �� Fax (516) 765-1823
MARRIAGE OFFICER � '`' ® Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3275-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner GRZESIK, MARIA
Mailing Address 1 1075 INLET LANE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 1075 INLET LANE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1388
Tax Map No. section 35.00 block 2 lot 21 .000
Cross Street MANHASSET AVENUE
Issue Date: 11/04/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE-OF THE TOWN CLERK OC���F�(�`;-
Town of Southold Z Q� Application No. 3 )7-
Judith T. Terry, Town Clerk ��� ; •
Town Hall, 53095 Main Road xK 1 ' -(-).--07----- Residential
P. 0. Box 1179 i.7 ,'
Southold, New York 11971 a �.-..,. .•��� $25.00 - Non-Residential
Telephone :Ol . �'�'' ''
(516) 765-1801am f
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Perit No.
Fee $ 7
DATE C// 5/ / f
J
OWNER fly /J2�7Ol� V //(
OWNER Niie DDRESS: 70 7 la --e____-
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OWNER PROPERTY ADDRESS:
ra•-e-f- ' —A.:"4&-=-:-z'6%=-A.e____
OWNER TELEPHONE NUMBER: 7, ' -_--7_51cr--
42- 6°---e---. TAX MA NO. : Section 3 Block �_ Lot �(
CROSS STREET: ,`� ' /%' ! ' ,--(,(--Q�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool .4 New Existing
z
Residential Non-Residential
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.)
414,
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Signature- of Appli j/ t
RECEIVED BY:
a Town Clerk's Office
DATE:
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