HomeMy WebLinkAboutPillepich s '
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JUDITH T.TERRY � � Fnsr ,7=t Town Hall,53095 Main Road
TOWN CLERK t "ns F:_' ; P.O.Box 1179
•s°'1', ,1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS • ce }' 1
•MARRIAGE OFFICER =e�/ „4°
Telephone(516)Fax(516)765-1823765-1800
RECORDS MANAGEMENT OFFICER d ED
FREEDOM OF INFORMATION OFFICER • oi
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3320-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner PILLEPICH, A. & M.
Mailing Address 1
Mailing Address 2
City St Zip 00000-0000
Property Address 1 COLUMBIA STREET
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 79.00 block 6 lot 10.000
Cross Street LIBERTY LANE
Issue Date: 4/26/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ' c��FFOU( --
Town of Southold �Q L'� Application No. 5 43.
Judith T. Terry, Town "Clerk' ` it ' Wim-
.�s:� ..0 $10.00 - Residential
Town Hall, 53095 Main Road .4*T:-. `: -
P. O. Box 1179 En .':',l' i ; $25.00 - Non-Residential
Southold, New York 11971 ' °® "*•' 0
Telephone Q 4( $ •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT '
, SEPTIC TANK or CESSPOOL
Operation,Permit No.
Fee $ /6: rte/
�0
. DATE 9
OWNER NAME: P/1-4, - p/6f7 go 4--- Iv)
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OWNER MAILING ADDRESS: Lc.1111jisz:} (1-71
OWNER PROPERTY ADDRESS: •J-07/7-716 ,,D ,�
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section 77 Block 6 Lot
d
CROSS STREET: .1-/66i -- 1_AM'LI"
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential I Non-Residential
DATE OF PREVIOUS PUMP-OUT: n
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/--1---?--- -' (
J
41114 ,
Signature of Applic. t
RECEIVED BY: AZ/ZZA-A----7--(--e__
Town Clerk's Office
DATE: A2 �� '9J
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