HomeMy WebLinkAboutPolistena Soc3
$� Town Hall, 53095 Main Road
�. J P.O. Box 1179
�`a®���� Southold, New York 11971
JUDITH T.TERRY „jr„„<
r���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. 686-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner POLISTENA, FRANK & DEBORAH
Mailing Address 1 BOX 667
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 CAPT. KIDD DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4625
Tax Map No. section 106. 00 block 2 lot 38. 000
Cross Street /,d)D , D
Date Of Last Pump Out 0/00/00
Issue Date: 5/03/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
u_>ZL7 V
OFFICE OF THE TOWN CLERK C§WFO(li -
Town of Southold �o. (4Application No. '�
Judith T. Terry, Town Clerk •
Town Hall, 53095 Main Roadc c £�
{R �' ; ' Residential
F.
nn O. Box 1179 Non-Residential
®
Southold, New York 11971 ® -to01.
Telephone :�.( It
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION •
for , ,
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / Q, 01)
DATE i/fib
OWNER NAME: Pru kA' &horr4 ileborodi Poi Il skin_
OWNER MAILING ADDRESS: B _ 6,0
, I 1 9 s--2
OWNER PROPERTY ADDRESS: Cc 4.' KW- Dr .
OWNER TELEPHONE NUMBER 6J 29 ?-
TAX MAP NO. : Section 10( Block �.� Lot 3 e
CROSS STREET: B h CA.k.t1.) )( ,
TYPE OF SYSTEM: Septic Tank New Existing
•
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: din
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.)
s- lea/tjM-1/7Pat;
Signature of Applicant
RECEIVED BY: 4.
CI`rk's office
DATE: Vr' V/ e
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