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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK •
® ge • P.O. Box 1179
da $ Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �® ��' Fax (516) 765-1823
MARRIAGE OFFICER = ojb �® ��' Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER 2i $ r�
FREEDOM OF INFORMATION OFFICERi ��l
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3235-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VITALE, MICHAEL AND JEAN
Mailing Address 1 225 MARLENE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 225 MARLENE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9672
Tax Map No. section 143.00 block 3 lot 31 .000
Cross Street ROUTE 25
Issue Date: 8/16/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• „
OFFICE OF THE TOWN CLERK cjVFFO(/, -
Town of Southold •� CQ Application No. <5.)-3 5
.NICTith T. Terry, Town Clerk
1. Town Hall, 53095 Main Road :� $10.00 - Residential
p. O. Box 1179 cr3 $25.00 - Non-Residential
Southold, New York 11971
Telephone �► •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
-OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ "OJ OU
DATE g y
OWNER NAME: 7))/d /71-X/ l-- / !7-A-LE J epi
OWNER MAILING ADDRESS: gcgs 717/9-0-- /V , 1&
rfl7 -i)16e, N. ) 161,ca-
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: oC 9 2'-96
TAX MAP NO. : Section Block -3 Lot 3/
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
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.)
17, .2<Z4(. .2.Z
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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