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I Town Hall, 53095 Main Road
0" P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY t41.h. � E -'
� TELEPHONE
TOWN CLERK � (516) 765-1801
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. 3670-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ZEVITS, ROBERT
Mailing Address 1 2470 ROSSETT STREET
Mailing Address 2
City St Zip FORT LEE NJ 07024-0000
Property Address 1 1300 WEST LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 201-944-9080
Tax Map No. section 88.00 block 6 lot 18.002
Cross Street
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Issue Date: 8/06/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'c$FOUr
Town of Southold kCSG' , Application No.36 70_
Judith T. Terry, Town Clerk .� :.u, 3
Town Hall, 53095 Main Road g `. 1 $10.00 - Residential /O, .7d
P. O. Box 1179 " $25.00 - Non-Residential
Southold, New York 11971
Telephone Jig
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O, Fay
DATE jut-y , 31 i cf C
OWNER NAME: Ror „,?k,1/4/71-1.5
OWNER MAILING ADDRESS: 1-1.7O RoSsfi i STA E a
Foie? 1 of � C R S E-Y 0 7oel1
OWNER PROPERTY ADDRESS: J EST
LOv i t-IOLI rlfEuJ Yo, k- rH9 71
OWNER TELEPHONE NUMBER: ( p 1" (344 9,0,63,O
TAX MAP NO. : Section g g Block L, Lot t g N
CROSS STREET:
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TYPE OF SYSTEM: , ,Septic-Tank . ` X _ 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.)
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Amor
Signature of Applicant
RECEIVED BY: _
Town-Clerk's -Office
DATE:
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