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JUDITH T.TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
, rftSouthold,New York 11971
REGISTRAR OF VITAL STATISTICS ® s r
MARRIAGE OFFICER Fax it or Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER `: :� � ali. Telephone (516) 765-1800
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. 3694-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CELESTE, NICHOLAS F.
Mailing Address 1 3215 DEEP HOLE DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3215 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5130
Tax Map No. section 115.00 block 16 lot 16.000
Cross Street THERESA DRIVE
Issue Date: 10/01/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK C3IFO(,(�
Town of.,Southold �� C'QG;� Application No.����
Judith T. Terry, Town Clerk .� . , y
Town Hall, 5'3095 Main Road -< $10.00 - Residential ✓
P. O. Box 1179 &Ft 44' $25.00 - Non-Residential
Southold, New York 11971 .4
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Telephone ( `��� �o
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 2:7-7—Y7
7
OWNER NAME: �/ �/fOGc��' � f•? � / /�z�
OWNER MAILING ADDRESS: /' ,lrg:;!/4 I/v�n sat .
A/ V
OWNER PROPERTY ADDRESS: c _ 4.0
OWNER TELEPHONE NUMBER: "7"f` Li /a
e.)
AC
TAX MAP NO. : Section /I ( Block / (o Lot /C
CROSS STREET: _ _
TYPE OF SYSTEM: Septic Tank New Existing `
Cesspool New • Existing 7
Residential /X-, 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.)
j '
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Signature of Applicant
RECEIVED BY: b(-)vCeih
Town Clerk's Office
DATE: 6 l77
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