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JUDITH T. TERRY 1.7e1Town Hall, 53095 Main Road
TOWN CLERK ® ryt P.O. Box 1179
ifs REGISTRAR OF VITAL STATISTICS ®� Fax (516) 765 Southold, New York 11971
1823
MARRIAGE OFFICER .` o$ 5-1
RECORDS MANAGEMENT OFFICER __�l 1 ,,., Telephone (516) 765-1801
FREEDOM OF INFORMATION OFFICER
OFFICEOF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3154-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BORKOWSKI, JOHN AND FAY
Mailing Address 1 29 HEIGHTS ROAD
Mailing Address 2
City St Zip NORTHPORT NY 11768-0000
Property Address 1 3300 MINNEHAHA BLVD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-261-6847
Tax Map No. section 87.00 block 3 lot 38.000
Cross Street OWAISSA AVENUE
Issue Date: 12/20/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,
OFFICE OF THE TOWN CLERK • sci\fFU( r��•_
Town of Southold � - /5
Application No.v
Judith T. Terry, Town Clerk `{'; µ ws
Town Hall, 53095 Main Road " -� $10.00— Residential 6.---"7
P. O. Box 1179 cn t_' i ; $25.00 - Non-Residential
Southold, New York 11971 Q _ ! s
Telephone O( * tk �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 6 SCC, 113
OWNER NAME: cpY\il �- 01'K.koWSk, I. t
OWNER MAILING ADDRESS: `ac'\ S •
.�
14,o 't t-At o R,� N.y _ 1 I -16%
OWNER PROPERTY ADDRESS: o o ri I ivP 61-In,HA 1LV b .
- S a d ‘.."b til 1,1c1--) .1
OWNER TELEPHONE NUMBER: S
TAX MAP NO. : Section 7:,') Block 3 . Lot 31
CROSS STREET: 0 W 1)15 .i- hU E
TYPE OF SYSTEM• Septic Tank A. New Existing )c
-ss.00l New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: I \Ism 1Iri l VMS R4°
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:
- 1
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