HomeMy WebLinkAboutCook, Donna x 1. ,,,,,,,,--
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ELIZABETH A. NEVILLE 0 Gy� Town Hall, 53095 Main Road
TOWN CLERK o - P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS v' S Southold, New York 11971
MARRIAGE OFFICER �, Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER y'flpl #a , Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER „•01
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4079-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner COOK, DONNA
Mailing Address 1 6900 MAIN BAYVIEW ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 SAME
Property Address 2
City St Zip 00000-0000
Owner Telephone No. 631-765-2956
Tax Map No. section 78.00 block 600 lot 800
Cross Street WATERVIEW (PRIVATE ROAD)
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Issue Date: 4/19/01 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �FFO"'
�� �C4 = Application No. a
ETH A.NE ILLE,TOWNOFSOUTTOWN CLERK �OLD �� of, Residential e-------
P.O.
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)�llZAB . cr)
�C � $10 00 -
P.O.$OX 1179
SOUTHOLD,NEW YORK 11971 f����/ $25.00 - Non-Residential
Telephone . ' * *P"...
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 439/0/
OWNER NAME: bomifr 6,0 ,
OWNER MAILING ADDRESS: O •/� 11 a,
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OWNER PROPERTY ADDRESS: j
OWNER TELEPHONE NUMBER: 1766----- ,)gsip
TAX MAP NO. : Section 70 , Block b Lot g. 0 I"
CROSS STREET:
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TYPE OF SYSTEM: Septic Tank A New Existing
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/
S7
Signature of Applican
RECEIVED BY: t "'"/
Town Clerk's ice
DATE: 0 ''' 7
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