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® • ®4.ELIZABETH A.NEVILLE Is_`�` ; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
et32 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS � Fax(516) 765-1823
MARRIAGE OFFICER %.44
4 Os Oil Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER ®� �� ��•
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3773-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ADLER, HERBERT J. JR.
Mailing Address 1 BOX 308
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2035 TOWN HARBOR LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3365
Tax Map No. section 66.00 block 1 lot 30.000
Cross Street TOWN HARBOR TERRACE
Issue Date: 3/05/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
773
OFFICE OF THE TOWN CLERK �c3I FD(,��"'
TOWN OF SOUTHOLDpP
Q Application No.s:
Dom. '"> ,C�='`
ELIZABETH A.NEVILLE,TOWNCLERK ` , ' ,r' A � $10.00 - Residential
P.O.BOX1179
cryt * '�' ► `' $25.00 - Non-Residential
1
SOUTHOLD,NEW YORK 1197
t��-���
• Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE AIs f
OWNER NAME: -e-wb , AAA .
OWNER MAILING ADDRESS: 3 e) c5
Sa__ iib L 1 7.5 . a f
OWNER PROPERTY ADDRESS: ®1.® &- - h� L.,.CLA-s-
jJ
OWNER TELEPHONE NUMBER: 5"/ (p -- — 33 OS
TAX MAP NO. : Section Vs'" Block Lot 3o
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool IV 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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•
Si.gure of Ap ant
RECEIVED BY: /\"-i /
Town Clerk ffice
DATE: 5 `��
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