HomeMy WebLinkAboutLaube, Gary ,I�,�o��SUEFOt,�►00 \
ELIZABETH A. NEVILLE ti'a� V Town Hall, 53095 Main Road
TOWN CLERK % o - ik P.O. Box 1179
tH Z $ Southold New York 11971
REGISTRAR,OF VITAL STATISTICS �► '
MARRIAGE OFFICER `` �i ��,�, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER =- "01 �a'�l' Telephone (631) 765-1800
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FREEDOM OF INFORMATION OFFICER ,, .��e���� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
operation Permit No. 4181-R Residential x Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner LAUBE, GARY
Mailing Address 1 P 0 BOX 1770
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 310 ACKERLY POND LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-765-6105
Tax Map No. section 70.00 block 5 lot 5.000
Cross Street LOWER ROAD
Issue Date: 1/02/03 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
:- )
Signa ur of Applicant
RECEIVED BY:
Town Mr ' Of lice
DATE: "-gal/
.'
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OFFICE OF THE TOWN CLERK C' FOUrz" /` 31
TOWN OF SOUTHOLD �� �lj Application No.7
ELIZABETH A.NEVILLE,TOWN CLERK � $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 �1; $25.00 - Non-Residential
Off''•
Telephone *0 ilk ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
34.
Operation Permit No. -3C--,11"1\ .-) , ...5-
Fee
10 5-Fee $
DATE I -Jd3
OWNER NAME: Gc..)...N\-\ L0.1�
OWNER MAILING ADDRESS: P 0 • ?j I O
� 01 Cv \ M- --1
OWNER PROPERTY ADDRESS: } O RC- `Y1y' c.)01\. ... LIAA-- .._.
OWNER TELEPHONE NUMBER: 1-L5- 61o5
TAX MAP NO. : Section ---)O Block 5 Lot 5
CROSS STREET: Lo Y Roc
TYPE OF SYSTEM: Septic Tank New ✓ Existing
Cesspool New ✓ Existing
Residential ✓ Non-Residential
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.)
11)
ei- or
Signa urf Applicant
ac.„:3
RECEIVED BY: „4 ( '-i,_
own 'Ter ' Of ice
DATE: . . 6
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