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Pemberton
c5s 010 Town Hall, 53095 Main Road 09) V-ALWit„ �'�.` P.O. Box 1179 _ ® ���! Southold, New York 11971 JIIDITH T.TERRY y�r-', FAX(516)765-1823 TOWN CLERK TELEPHONE(516)765-1801 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. 1159-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner PEMBERTON, JESSIE Mailing Address 1 OLD MAIN ROAD Mailing Address 2 City St Zip ORIENT NY 11957-0000 Property Address 1 OLD MAIN ROAD Property Address 2 City St Zip ORIENT NY 11957-0000 Owner Telephone No. 516-323-3585 Tax Map No. section 14.00 block 2 lot 3.002 Cross Street GRAND VIEW DRIVE Date Of Last Pump Out 0/00/00 Issue Date: 6/16/89 Judith T. Terry Southold Town Clerk (TOWN SEAL) o OFFICE OF THE TOWN CLERK •z\WFU(K Town of Southold Application No. // Judith T. Terry, Town Clerk �� ' �. Town Hall, 53095 Main Road Residential X �mfr �, _ P. O. Box 1179 [n �-•� �x .�z � . 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 $ • DATE 007 OWNER NAME: }, OWNER MAILING ADDRESS: 9L() ,4, 2/ ) 4=7,2,D 69e/er.e.)i // Y 7/(97-C7 OWNER PROPERTY ADDRESS: 04_,,,,48--) OWNER TELEPHONE NUMBER: 7& 'Q23_ 56.745-- 1 TAX MAP NO. : Section '7795 Block Lot CROSS STREET: ,�Gb i.14/i PC3 Z TYPE OF SYSTEM: Septic Tank t/ New Existing Cesspool New Existing t Residential /Non-Residential DATE OF PREVIOUS PUMP-OUT: /ter 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.) amlultrYLi Signature of Applicant RECEIVED BY: Town Clerk's Office DATE: S, --14v. -'0o E. 272 .©4- L 779 zzl I ri E - in 1 • -\--------------"A _________-\------------ I... s ComP'° '' / X ,s c, , _ ' `✓ \ 01-1. S 36-----q0 \[ 1i r . i 2- -S7v#067 17:90‘i-fa . 1 i O • ,.., ... . . _ _ _ ra N 0 � ,1 N 75° 50 oc9` ,--' 0 L0 ' I' is I A-