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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK h P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ..` Southold, New York 11971
MARRIAGE OFFICER
e� O � Fax (516) 765-1823
0- 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. 1871-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VOLINSKI, MARK A. g KARENANN W
Mailing Address 1 P. O. BOX 208
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 445 DEER DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8867
Tax Map No. section 114.00 block 10 lot 12.000
Cross Street CINDY LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/09/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �cv�Fair °- �. /
Town of Southold -,CQ Application No. f?'7
Judith T. Terry, Town Clerk % "�* .
' "t : �G ) $10.00 - Residential [J
Town Hall, 53095 Main Road � --=
P. O. Box 1179 cry "= _'_ �' $25.00 - Non-Residential
Southold, New York 11971 O"i *``~.::. ��`
Telephone .0?e Izie 't "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION -
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ h�' - - � - -- ------ ---- - -- - - --
DATE 1 ,
OWNER NAME: NA-Re 4, 4- 4Pt:edAlai 6tJ. 1/0 L.mi 3 :f
OWNER MAILING ADDRESS: &,,y- 04yr
n44i7MC4 4!Y 111��
OWNER PROPERTY ADDRESS: 4f � i2 a , -
il— ack i 1/1.6-
OWNER TELEPHONES NUMBER: St& r/ t97
TAX MAP NO. : Section 1i 1' Block I o Lot
CROSS STREET: ei,i/atit tii-/V "
-
TYPE XOF,SYSTEM: Septic Tank - New Cxistin •
d
Cesspool / New Existing
(Rresidential Non-Residential -
DATE OF PREVIOUS PUMP-OUT: (JA1(/Lj 4J4J
LOCATION-MAP: Must be attached hereto before permit maybe issued.
(Locate building and system; give north arrow and feet '
of distance, approximately, to building and closest road.)
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Signature of Applicant 'b & -Deli/
Town Clerk's Office
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DATE: - '
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