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Town Hall, 53095 Main Road
R%' O �, P.O. Box 1179
'••••� Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1168-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DAWSON, JAMES W. & PATRICIA G.
Mailing Address 1 9 STONELEDGE ROAD
Mailing Address 2
City St Zip UPPER SADDLE RIVER NJ 07458-0000
Property Address 1 9700 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 201-327-7472
Tax Map No. section 31 .00 block 10 lot 4.000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/23/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
see
OFFICE OF THE TOWN CLERK 'cOFO(,r -
Town of Southold Application No. 1/67
Judith T. Terry, Town Clerk �� 447 k‹.1* /
Town Hall, 53095 Main Road o _ ru Residential �/
P. O. Box 1179 ��` Non-Residential
Southold, New York 11971 O ' 40�.�`
Telephone (,1. 1% �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
1/Fee $ lO
DATE June 12, 1989
OWNER NAME: James W. & Patricia G. Dawson
OWNER MAILING ADDRESS: 9 Stoneledge Road
Upper Saddle River, NJ 07458
OWNER PROPERTY ADDRESS: 9700 Main Road
East Marion, NY 11939
OWNER TELEPHONE NUMBER: 201-327-7472
• TAX MAP NO. : Section 031 Block 10 Lot 04
CROSS STREET: 300 ' e/o Bay Avenue
TYPE OF SYSTEM: Septic Tank New Existing X
Cesspool New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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