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JUDITH T.TERRY � �® t Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
�
y. �4 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O Fax(516) 765-1823
MARRIAGE OFFICER491
Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER --- ,� �1
FREEDOM OF INFORMATION OFFICER -'I,,
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3635-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FALLETI, LILLIAN M.
Mailing Address 1 762 NAUGLES DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 762 NAUGLES DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9699
Tax Map No. section 99.00 block 5 lot 12.004
Cross Street BREAKWATER ROAD
Issue Date: 5/22/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK /S�FFU(K
Town of Southold �� CQG Application No.cJ
Judith T. Terry, Town Clerk :1
Town Hall, 53095 Main Road I $10.00 - Residential
P. O. Box 1179 �`
' $25.00 - Non-Residential
Southold, New York 11971 ® '` �$
Telephone
(516) 765-1801 - 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /()i
DATEhi ,c7) 11
OWNER NAME: A,ffigh _ML.I` l e_,4-, ' _
OWNER MAILING ADDRESS: 7/A /U
c-
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: ,5/‘_c2-.YST-- , ��
TAX MAP NO. : Section Y-73 g5-7-5,-Block Lot /a.-Doc
CROSS STREET : A F-eaj2 CJS .,
TYPE OF SYSTEM: Septic Tank d _New Existing
Cesspool / New Existing i/
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.)
Signature of Applicant
RECEIVED BY:
Town clerk's Office
DATE:
"3' C)5- ' -- ._ ��'f:= :vofg --- - rv� w.4• , :w -�.�_--- '-- -547. ^7 _ -1 - — THE WATER SUPPLY ANI
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