HomeMy WebLinkAboutPierson 1100 la'
y 0474
® . Town Hall, 53095 Main Road
JUDITH T. TERRY ' �`,
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER >� � Fax (516) 765-1823
®� ,ss��, ��® 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. 1938-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PIERSON, RICHARD
Mailing Address 1 P. O. BOX 1028
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 5245 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5606
Tax Map No. section 79.00 block 3 lot 20.000
Cross Street SHIPS DRIVE
Date Of Last Pump Out 0/00/85
Issue Date: 6/25/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OFTHE TOWN CLERK c0FO(,r °"
T9w1h of Southold CQ ' . Application No. /13f
Judith T. Terry, Town Clerk � • y I $10.00 - Residential
Town Hall, 53095 Main Road o �YY
p. O. Box 1179 v' 1 : AAA ' : $25.00 - Non-Residential
Southold, New York 11971 Ory, _;� fA'
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0° 0-f)
DATE e/or5190?
OWNER NAME:
OWNER MAILING ADDRESS: - S. /go/ /0' 2B
OWNER PROPERTY ADDRESS: of Y- ?)44,21--i c ,ur .
OWNER TELEPHONE NUMBER: (/0 7 S - .546 �o
TAX MAP NO. : Section 7 Block 3 Lot c2 0
CROSS STREET: U �--e—
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool k.// New Existing L/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
/t Signature of Applicant
11111 RECEIVED BY:
ily•wn Clerk's Office
DATE:
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