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Town Hall, 53095 Main Road
O ;�� P.O. Box 1179
:4t1/ �r Vii! Southold, New York 11971
JUDITH T.TERRYFAX(516 765-1823
TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1283-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROSENBERG, WERNER
Mailing Address 1 100 LA SALLE STREET
Mailing Address 2
City St Zip NEW YORK NY 10027-0000
Property Address 1 22035 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 212-929-3124
Tax Map No. section 135.00 block 1 lot 12.000
Cross Street GOLDIN LANE
Date Of Last Pump Out 0/00/85
Issue Date: 10/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'cOFn�K •
-�
Town of Southold C'OGy p P A lication No.
0�� -- .
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road " ' $10.00 - Residential fg
P. O. Box 1179 �
$25.00 - Non-Residential
Southold, New York 11971 O " 3- ''
tr
Telephone Q( 44 V
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE (19/20197/
OWNER NAME: LcJr 2Jr Z R.6 S/=liil3,^IZ c. • .
OWNER MAILING ADDRESS: /0(9 t ,4 cA.L.LerS/
Ne_v1 wired- N_`' 1 0 D 7)
OWNER PROPERTY ADDRESS: Z2,�3 Sp 1 1 jJ �E �/ �Jt^ SQ %ajd
OWNER TELEPHONE NUMBER: Z12 cf2 q - 312y
TAX MAP NO. : Section / 3 5 Block S Lot l•,)_}
CROSS STREET: CrlgL 1 jJ LA-NeQ
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 4? �?
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 Applican
RECEIVED BY:
Town Clerk's Office
DATE:
,7iAUTNORiEED AI.,L.2•tE.✓.-.,..,R nd'DII Os
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