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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERKP.O. Box 1179
REGISTRAR OF VITAL STATISTICS 171
S 2
Southold, New York 11971
MARRIAGE OFFICER i ��� Fax (516) 765-1823
VA. AV ' Telephone (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. 1630-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROSIN, HEINZ
Mailing Address 1 P. O. BOX 518
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 5610 PECON I C BAY BLVD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5028
Tax Map No. section 128.00 block 2 lot 10.000
Cross Street BIRCH DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 2/27/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I� III'
OFFICE OF THE TOWN CLERK � FO(,r�
Town of Southold O C� � , Application No./62 'O
Judith T. Terry, Town Clerk ' zf' 3,1.5A-41
Town Hall, 53095 Main Road $10.00 — Residential
P. O. Box 1179 5' .401
Telephone
+V3-4 $25.00 - Non-Residential
®
Southold, New York 11971 0* st. : �$
Telephone _01 , ".
.41
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
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Operation Permit No. /&
Fee $ ��,
DATES �.�u:, 199/
OWNER NAME: yam,// / s •
OWNER MAILING ADDRESS: P®10)("/ .>'"6/®", dpcive.1W152.4-'
/17V.- /1'4g
OWNER PROPERTY ADDRESS: (SA'f�'l,6 i - - -- __
OWNER TELEPHONE NUMBER: 576-29g---...5-02-8
TAX MAP NO. : Section /263 Block G. Lot /U
CROSS STREET: ZeZe
j�
TYPE OF SYSTEM: Septic -Tank::: New Existing '
Cesspool V New Existing V
Residential •,4V Non-Residential
DATE OF PREVIOUS PUMP-OUT: rid r 77i
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.)
CY,
-; (.J��_
Srture of Applicant
RECEIVED BY: X ,
Town Clerk's Office
DATE:, J/62.4/9 (/
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. SURVEY FOR f '
- - HEINZ - ROSIN. B BRIGITTA ROSIN ' - : ' -
, ' LAUREL
TOWN OF SOUTHOLD _ _ :•
SUFF.,, CO., N.Y.' GUARANTEED TO: ,
. - ' . NORTH FORK BANK a-TRUST CO.' ` .
„ " SCALE I" = 40' INTER -COUNTY TITLE GUARANTYa
AUG 31,. 19E 5 MORTGAGE Cp..; •
■ a MONUM,EN.T i .,
PROFESSIONAL ENGINE AND
' ,LAND SURVEYOR,N.Y.S. •C:NO.12846
. ,. RIVERHEAD, N.Y.,