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JUDITH T. TERRY
" Town Hall, 53095 Main Road
TOWN CLERK c ) { P.O. Box 1179
REGISTRAR OF VITAL STATISTICS @ Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
/y &t ! 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. 3065-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WOLANSKI, TELESPHORE
Mailing Address 1 50575 NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 50575 NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2616
Tax Map No. section 51 .00 block 3 lot 11 .000
Cross Street CLARK ROAD
Date Of Last Pump Out 6/00/91
Issue Date: 7/21/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 0SWFd(,(��.
Town of SoutholdrT,�=. CQG Application No.3665—
Judith T. Terry, Town Clerk OHOG ilk a �°
.•C $10.00 - Residential p .e-0
Town Hall, 53095 Main Road c
P. O. Box 1179 � . : $25.00 - Non-Residential
Southold, New York 11971 4.` �0�,��
Telephone _ 1zid
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION RECEIVE
for JUL 15 1993
OPERATION PERMIT Southold Town'Clerk
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE .7—
OWNER NAME: -72/0 9pJ ate) 1394
OWNER MAILING ADDRESS: ,g7- �oo�!
S � � ) k) . y
OWNER PROPERTY ADDRESS: S'0 /?C
OWNER TELEPHONE NUMBER: (5-7 - 745.— a 6.14
TAX MAP NO. : Section 6--/ Block � Lot //
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1 - 9
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.)
- Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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