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JUDITH T.TERRY ® F _w Town Hall,53095 Main Road
TOWN CLERK chip 'yP.O.Box 1179
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® . . 'W Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ' " MrFax(516)765-1823
MARRIAGE OFFICER
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RECORDS MANAGEMENT OFFICER � Eg d"�� Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,0
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3341-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PHARR, PAULINE
Mailing Address 1 P. O. BOX 958
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 360 SOUTH HARBOR ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1204
Tax Map No. section 75.00 block 3 lot 7.000
Cross Street MAIN ROAD
Issue Date: 5/19/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• .•.
OFFICE OF THE TOWN CLERK �F �CQ
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- Town of Southold NQS Application No.3
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road • -4 ) $10.00 :- Residential
P. O. Box 1179 cn • ;' $25.00 - Non-Residential
Southold, New York 11971 O2 *.$
Telephone e/ jit ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for.
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATEC) /611c;
OWNER NAME: 6.)( 141-)HZ 6-)NA4e.,_�p
OWNER MAILING ADDRESS: 0,0. 63ssf
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OWNER PROPERTY ADDRESS: 'adv �• )1hr tzd It, RD
Soi,-11� �V I/i
OWNER TELEPHONE NUMBER: -765' )1o/i
TAX MAP NO. : Section 0-7 Block 3 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing 4/
J
Cesspool New Existing
Residential 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.)
.i i1.
Signature of pplicant
RECEIVED BY: (-X) Api
Toic• - 's Office
DATE:
• MAY 1 9 1995
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