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JUDITH T.TERRY � $ t ,�t± ��®: Town Hall, 53095 Main Road
TOWN CLERK ® � .� ; P.O. Box 1179
' z. P �` Southold,New York 11971
REGISTRAR OF VITAL STATISTICS `® t"� 823
Fax(516) 765-1
MARRIAGE OFFICER =t*'j ' ,s �� Telephone(516) 71823
RECORDS MANAGEMENT OFFICER = 'i�
5-1800
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. 3748-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MITCHELL, ROBERT E. & ANNE N.
Mailing Address 1 3905 WELLS ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 3905 WELLS ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-1944
Tax Map No. section 86.00 block 2 lot 14.000
Cross Street MAIN ROAD
Issue Date: 12/04/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �C�IRV(-�-
Town of Southold � , 4r Application No. 37 Y
Judith T. Terry, Town Clerk .� � y
Town Hall, 53095 Main Road g .; • $10.00 - Residential
�'
P. O. Box 1179 : ft,- ;' $25.00 - Non-Residential
Southold, New York 11971 O :` ' *-$
Telephone Z7Q1 0
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ja
DATE ,N11UL74l5/ 1L VI, I e 67
OWNER NAME: R.0 ,'072 * pit/A/ At, /NA (T'"G2f d—
OWNER MAILING ADDRESS: 343° S- 1A11=_ /Z&/ HD
/' cc -"c. e-' `X It95e
OWNER PROPERTY ADDRESS : 3 E° tv 5 175`D
Popirzc. Ai it 9 I 'b
OWNER TELEPHONE NUMBER: Cir`-6 ) t' —199 L/
TAX MAP NO. : Section 3 6 Block 2- Lot I LI
boot
CROSS STREET: 1,,./ -L-Ls. /?&p-.p by c-As z-i s m s°+riti , 0A- D
TYPE OF SYSTEM: Septic Tank New Existing '.-----
Cesspool New Existing
Residential a�---- 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.)
1/113411f
Signature of Applicant
RECEIVED BY:
_Z
Town Clerk's 0 ' e
DATE: GQ/V 9 " •
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