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JUDITH T. TERRY Town Hall, 53095 Main Road
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TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ® ®�
Fax (516) 765-1823
6P4 sb . Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2051-R Residential X Non-Residential •
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VOLINSKI, JOHN J.
Mailing Address 1 RR 1, 1525 SHIPYARD LANE
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 1525 SHIPYARD LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2236
Tax Map No. section 38.00 block 1 lot 16.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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0A7,Fl•CE OF THE TOWN CLERK
_ Town of Southold Q� FOC CQG' Application No. 0S
Judith T. Terry, Town Clerk
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Town Hall, 53095 Main Road � 1 $10.00 - Residential
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P. O. Box 1179 vs Ki-164 z $25.00 - Non-Residential
Southold, New York 11971 O ' 'i 1�'�
Telephone °j yti
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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.
Fee $
DATE 16113
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"3-ZD Ni61ii.s �
OWNER NAME:
OWNER MAILING ADDRESS: ,eO1 15 - 1\ i\ard 4.44
ash M ,rko( I Llct&5'
OWNER PROPERTY ADDRESS! - - - - -
OWNER TELEPHONE NUMBER: Y - 2-2
TAX MAP NO. : Section 11 � Block 3 6 Lot
=CROSS STREET: Ccli
TYPE,OF.-SYSTEM:--Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: c- 6( (o e'4^\ l _1-4014 eatt JR.('
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.)
liAb )/6"
r Si S
ature of Applicant
RECEIVED-:BY: ,_ _ _
Town Clerk's Office
DATE: . _ - _"
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