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8 ittti �. Town Hall, 53095 Main Road
,I=- 'T$ P.O. Box 1179
® - . -° o��r` Southold, New York 11971
JUDITH T.TERRY `1 ®2 Cw,,,,, -i 11,1 TELEPHONE
row CLERK '-mw° (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. 74-N Residential Non-Residential X
Fee $ 25. 00 Septic Cesspool X
New Existing X
Name Of Owner VOLINSKI , BENJAMIN
Mailing Address 1 VOLINSKI OLDS, INC.
Mailing Address ,2 P. O. BOX 761
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 TRAVELER STREET
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3222
Tax Map No. section 60. 00 block 2 lot 2.000
Cross Street YOUNGS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/30/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of SoutholdApplication No.
Judith T. Terry, Town Clerk �` S �► _
Town Hall, 53095 Main Road c �
Residential
P. O. Box 1179 A ; Non-Residential
Southold, New York 11971 O • `c'
dte_ , ..1.c\‘1-/
r
Telephone 1
(516) 765-1801.
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $ tac.
1,7g/ff-
-
OWNER NAME: E.Ak1 nt/4l V
OWNER MAILING ADDRESS: P Bo?c 76f
sou-6101,0 Ny tiff?,
OWNER PROPERTY ADDR SS: co WS ek Youl1 'u �¢ vet.e _
(Vowa kr ®E. ' 'me S'dgerl--61- ti It t7/
OWNER TELEPHONE NUMBER: _64; - 32...,1 ?—
TAX
2... l ,TAX MAP NO. : Section 40 Block Lot 02
CROSS STREET:
?IthirA)4,5 -4- CtA
TYPE OF SYSTEM: Septic Tank New Existing xx
Cesspool New ' Existing f
Residential Non-Residential f '
DATE OF PREVIOUS PUMP-OUT: 0 — .347
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.)
/ 47 .- • VO4:40elj
Sig -cure o AID lic n�
RECEIVED BY:
Town Clerk's Office
DATE:
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