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JUDITH T.TERRY t9$11 ' . Town Hall, 53095 Main Road
TOWN CLERK : y_ _ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
'iv � Southold,New York 11971
MARRIAGE OFFICER `��?° Fax Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER 0.( * Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER os'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3535-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WELLS-SOUTH HARBOR CORP.
Mailing Address 1 C/O NANCY WELLS
Mailing Address 2 121 BELLEVUE AVENUE
City St Zip MONTCLAIR NJ 07043-2216,
Property Address 1 650 OLD WOOD PATH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 201-746-0332
Tax Map No. section 87.00 block 1 lot 19.000
Cross Street SOUTH HARBOR ROAD
Issue Date: 10/24/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cOFO(A,
Town of Southold , Deo CQ Application No.3
Judith T. Terry, Town ClerkF,
Town Hall, 53095 Main Road $10.00 - Residential
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P. O. Box 1179 �' '� _ �' $25.00 - Non-Residential
Southold, New York 11971 O
Telephone _ ! y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ O().
DATE / /_c 1 zc
OWNER NAME: (/U/J3 -c�(�l/Z� ri '- f ( 6,7 6)C/
OWNER MAILING ADDRESS: /6.1- devut awe,,
_g_or)pd 4/ q; 070
OWNER PROPERTY ADDRESS: 66---0 04( piit
n
OWNER TELEPHONE NUMBER : AO/j 7 (("(9 j jam.
TAX MAP NO. : Section e5--i Block / Lot /7
CROSS STREET: Sc j f( . c5 g, 4L-
TYPE- OF SYSTEM: :Septic 'Tank = New Existing
•
Cesspoolp1 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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"461-?.rnae of Applicant
RECEIVED BY: , -
Town Clerk's Office
DATE: -
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