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B , F,c ;; Town Hall, 53095 Main Road
F,, .% P.O. Box 1179
":.i;l �`Vit! Southold, New York 11971
JUDITH T.TERRY 1 ETAI ..'1' TELEPHONE
fOWN CLERK '''.wiiitii. (516) 765-1801
REGISTRAR 01 VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 937-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROTHMAN, ROBERT
Mailing Address 1 BOX 878
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 54100 MAIN STREET
Property Address 2 (APT. LOCATED BEHIND STORE)
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3770
Tax Map No. section 61 .00 block 4 lot 20.000
Cross Street MECHANIC STREET
Date Of Last Pump Out 0/00/00
Issue Date: 11/30/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK -
Town of Southold ��� CQG' Application No.
'1,4'44"1-c;
Judith T. Terry, Town Clerk w4="1 •�
Town Hall, 53095 Main Road :G Residential
cn :.A
'P.� O. Box 1179 �y4 � y � ;' Non-Residential
Southold, New York 11971
Telephone _ 10 �.,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
NOV 2 9 1for
von Cted W OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE OV 2 8 1988
OWNER NAME: 7'th4 �
OWNER MAILING ADDRESS: AO) 2R7?
OWNER PROPERTY ADDRESS: /em zAz r- Antl�
v rrz f
' OWNER TELEPHONE NUMBER: ")(ac> 3
TAX MAP NO. : Section CO Block 7 Lot L 0
CROSS STREET: a
TYPE OF SYSTEM: Septic Tank v' , New Existing
Cesspool New , Existing
Residential 7- Non-Residential
DATE OF PREVIOUS PUMP-OUT.: CJ'Ap IGA/c)• A/r
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north 'ar'row and feet
of distance, approximately, to building and closest road.)
_
• ,
Signature of Applicant
RECEIVED BY: ..el�r - ) •
Townrk's Of is - -
DATE: )72_4-0, "=`, /9 - , ,
NI Pr 1 :Vd4/ 0 A-3
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