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JUDITH T. TERRY % l+ Town Hall, 53095 Main Road
TOWN CLERK zt p T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �` Southold, New York 11971
MARRIAGE OFFICER -T 0. ,l, Fax (516) 765-1823
--_ ,0 + �1D,� Telephone (516) 765 1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2026-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ADLER, FRED
Mailing Address 1 BOX 1481
Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
Property Address 1 520 LAKESIDE DRIVE SOUTH
Property Address 2
City St Zip SOUTHODL NY 11971-0000
Owner Telephone No. 516-765-3418
Tax Map No. section 90.00 block 3 lot 17.000
Cross Street CEDAR BEACH PARK DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 12/23/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c,V�FUC,Y '-
Town of Southold � CQ ' Application NoQ0o
Judith T. Terry, Town Clerk . f �►
Town Hall, 53095 Main Road _` _ x - $10.00 - Residential
cnesti
P. O. Box 1179 L $25.00 - Non-Residential
Southold, New York 11971 Off` : .Or/
Telephone ®,(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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for RECEIVED
•
OPERATION PERMIT DEC 17 1992
SEPTIC TANK or CESSPOOL Southold Town Clerk
Operation Permit No.
$ l0G°
Fee -
•
DATE ( Z // ?(Fz----
OWNER
NAME: /ceL) ,DLC,
OWNER MAILING ADDRESS: 436, / 5-5-( �ourhOLL7 /(”
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OWNER PROPERTY ADDRESS: 3-2-0 iAltr.
OWNER TELEPHONE NUMBER: C
TAX MAP NO. : Section / Block Lot /7
CROSS STREET: c)(0-1
TYPE "OF "SYSTEM: Septic Tank -/ New Existing
Cesspool ✓ New Existing ✓
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
LCA
Signature of Applicant
OPP
RECEIVED. BY: t( Of - - - - --
ow -rk's fic
DATE: ` & / 7-
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