HomeMy WebLinkAboutOvsianik ette
Town Hall, 53095 Main Road
�t% P.O. Box 1179
_ ®� 0 •V iso Southold, New York 11971
JUDITH T.TERRY ,/ii���� FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1027-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner OVSIANIK, JENNIE
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3781
Tax Map No. section 75.00 block 2 lot 5.000
Cross Street MAPLE AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/17/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �S\WHO'- ..Town of Southold c� w CQ - Application No. l(��. 7
Judith T. Terry, Town Clerk % t :eP �►
Town Hall, 53095 Main Road /,,r f„ .r< 1 Residential
P. O. Box 1179 cn t4•-- K-2.-:1-..1• �' Non-Residential
Southold, New York 11971 O �$
Telephone *lift'
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No./0 .
Fee $ )1:;:n DT)
DATE a. 113- _.�
OWNER NAME: J 'e_c\y- ii CD\I \ 0 '(\ k.l
,V,
OWNER MAILING ADDRESS: - ' Ckz \
, (-.; U. -moi, \ 1 l3 , \ 1c.1 1-1
OWNER PROPERTY ADDRESS: r6 zc� c______-
OWNER TELEPHONE NUMBER: c) 6P —4- 6 J — 3 4- 1 I
TAX MAP NO. : Section -1 `,---- Block ')-- Lot
CROSS STREET: Ma p 1 Q , /4 V� 0(/Z____-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: q ) r)+ k
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.)
F,,,---..i.e— O r
Signature of Applicant
RECEIVED BY:
e Clerk's Office
DATE:
FEB 1 ; ��
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