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Ovsianik
JUDITH T. TERRY Town Hall, 53095 Main Road TOWN CLERK ® Fra P.O. Box 1179 REGISTRAR OF VITAL STATISTICS Er% Southold, New York 11971 MARRIAGE OFFICER ® �.. //, Fax (516) 765-1823 ®1 �b _ 0'r Telephone (516) 765-1801 -sr OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 138-N Residential Non-Residential X Fee $ 25.00 Septic Cesspool X New Existing X Name Of Owner OVSIANIK, ALLEN W. Mailing Address 1 8490 SOUNDVIEW AVENUE Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address 1 MAIN ROAD Property Address 2 City St Zip CUTCHOGUE NY 11935-0000 Owner Telephone No. 516-7311-7395 Tax Map No. section 97.00 block 2 lot 15.000 Cross Street EUGENES ROAD Date Of Last Pump Out 0/00/00 Issue Date: 3/09/93 Judith T. Terry Southold Town Clerk (TOWN SEAL) r �A !OFFICE OF THE TOWN CLERK COFO(,r��=_ / 3 Town of Southold ��� =: CQG- Application No. / Judith T. Terry, Town Clerk +` tiu �.C�I $10.00 - Residential Town Hall, 53095 Main Road £_` P. O. Box 1179 '` `r $25.00 - Non-Residential / v' � ��.'��.� '� . ` vim ` • • -� Southold, New York 11971 ,�` Telephone Vat:*Ng (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION -- - " - - - -- - ---- for - = ----- _ .- - - OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. , Go Fee $ e2� DATE --S/1/7/1"? OWNER NAME: A04 I/S/1 e,ti7 OWNER MAILING ADDRESS: NV% Sc),-41/2244, r /m7( OWNER PROPERTY ADDRESS: AfE-Ar Pi" (3r-W-kf0�" OWNER TELEPHONE NUMBER: ! TAX MAP NO. : Section P97 Block ©a Lot (9/..c CROSS STREET: eiiy&wt TYPE OF-SYSTEM: Septic Tank New Existing Cesspool ✓ New Existing Residential 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.) • ;//6/1-1 Signature of Applicant RECEIVED BY: - Town Clerk's Office DATE: 1Y