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JUDITH T.TERRY 11OG1 ‘ Town Hall, 53095 Main Road
TOWN CLERK ko P.O. Box 1179
� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O �� Fax(516) 765-1823
MARRIAGE OFFICER /
RECORDS MANAGEMENT OFFICER 491 *
�a 1°‘ Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER - 's°
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3664-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner NOBILE JOSEPH AND CAMILLE
Mailing Address 1 400 WELLS ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 400 WELLS ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-1934
Tax Map No. section 126.00 block 9 lot 3.000
Cross Street ALBO DRIVE
Issue Date: 7/23/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK etir
Town of Southold , 0��� COG,� Application No. �
Judith T. Terry, Town Clerk ,,.•,"
Town Hall, 53095 Main Road x ` $10.00 - Residential
P. O. Box 1179 LI-3 ,," •. p-' ��`' $25.00 - Non-Residential
Southold, New York 11971 O 0 Y'y'=� . 't- ss
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 7/;377
7
OWNER NAME: c 1%44._ t de-Afft;(4 /c)644_
/
OWNER MAILING ADDRESS: �� (Aid "Q
)0&4i /0
OWNER PROPERTY ADDRESS: 9.-t--_<_ a-t�e- `�-
OWNER TELEPHONE NUMBER: �P- /9.3V
j TAX MAP NO. : Section ( 2-4- Block , Lot 3
CROSS STREET: --/V4v - __( �•
TYPE OF SYSTEM: Septic Tank , • NewExisting
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.)
(L, ( ,.
Si na 1 of App icaht
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