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Town Hall,T. TERRY :� a , `' 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER r Fax (516) 765-1823
toTelephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1772-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WELISEK, OLGA AND HELEN
Mailing Address 1 P. O. BOX 784
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 305 OLD SHIPYARD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2631
Tax Map No. section 64.00 block 5 lot 4.000
Cross Street L'HOMMEDIEU
Date Of Last Pump Out 8/08/89
Issue Date: 9/30/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
-OFFICE OF THE TOWN CLERK •C.0Fair
Town of Southold ‹,' .4.-'4'. (4.1; Application No. r? -2 .-
Judith
-Judith T. Terry, Town Clerk . . lik 1.5..v::1::,
Town Hall, 53095 Main Road c i -;14.-,;-4?:,- $10.00 - Residential
P. O. Box 1179 in J �` $25.00 - Non-Residential
Southold, New York 11971 OLS �• .
Telephone �j 41 ��e• •"
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
,OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /77
Fee $ /0--------
1 0--------
DATE SRI: A,d ( 7,1
7
OWNER NAME: i r./ 4_,L4- ,r4 C s K.
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OWNER MAILING ADDRESS: O..{D J9/,y ,t S
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OWNER PROPERTY ADDRESS: 30...rezi).�*-#74,w - / 7I'e7i
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OWNER TELEPHONE NUMBER: t/7‘ ,..(--- /
TAX MAP NO. : Section Block („,, ,4-..-e-ft-Lot ,ts�-F-�:-T
CROSS STREET: 4/1-727Leipfri/Dbi , 2=-A-1F
° TYPE OF SYSTEM: Septic Tank New Existing
- -- Cesspool / New Existing 17
.. Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: _
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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.)
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S' nature of Applica t
RECEIVED BY: Xl /`+
Town Clerk's Of ice
DATE: c 19-
117: — 4&sT 6957—
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