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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ,1 T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Fax Southold, New York 11971
F (516) 765-1823
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MARRIAGE OFFICER ®
® � Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3165-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BELSTEN, ROBERT AND ELISA
Mailing Address 1 3650 OLE JULE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3650 OLE JULE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-3891pp
Tax Map No. section X96' blod lot 2S-UO T
Cross Street KRAUS ROAD
Issue Date: 1/12/9 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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