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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK G P.O.P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER ‘y Fax (516) 765-1823
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* IR 0' 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. 3125-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PEARSON, JOHN W., M.D.
Mailing Address 1 3258 SOUTH HARBOR ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 3258 SOUTH HARBOR ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5782
Tax Map No. section 75.00 block 7 lot 6.000
Cross Street HIAWATHAS PATH
Date Of Last Pump Out 0/00/00
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c,VFF[1(,Ur.a.= • /�5
Town of Southold �� CQG Application No.
Judith T. Terry, Town Clerk, y ,/
Town Hall, 53095 Main Road _ `. "� $10.00 - Residential
p. O. Box 1179 J' hzi $25.00 - Non-Residential
Southold, New York 11971 O �O�'►`�
Telephone ( *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATiON
for
• OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 00
DATE -S-eK4 cc,1,1 3
OWNER NAME: ‹I, (91.A.
OWNER MAILING ADDRESS: 3 2-n'. . L4-Fvl, O�- eA.
-go-0-1- J 7/
OWNER PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: 76,x= S7 0 Z---
TAX
TAX MAP NO. : Section t-0.3 et? Block 7S—?- Lot
CROSS STREET: -► t Sr(
TYPE OF._SYSTEM: SepticTank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS ,PUMP-OUT: 4LA-1
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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ignature of Applicant
•
RECEIVEDEt
tgow
own- Clerk's Office
DATE: SEP 21= i94.1
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