HomeMy WebLinkAboutCornell, Clifford (2) ,e- ..
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ELIZABETH A.NEVILLE 0 y‘; Town Hall, 53095 Main Road
TOWN CLERK i o � ik P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS
t W Southold, New York 11971
�� Fax (631) 765-6145
MARRIAGE OFFICER :�ifiL � /1
RECORDS MANAGEMENT OFFICER VS* �a�,// Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ���/ southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4126-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner CORNELL, CLIFFORD
Mailing Address 1 10946 NORTH BAYVIEW ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 10946 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-765-9105
Tax Map No. section 79.00 block 5 lot 20.008
Cross Street SEAWOOD DRIVE
Issue Date: 1/30/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK '•��' U `�
TOWN OF SOUTHOLD ;�� `1 L�1 Q Application N
ELIZABETH A.NEWT F,TOWN CLERK P Pio.
P.O.BOX 1179 Construction
SOUTHOLD,NEW YORK 11971 �_
• tie yc Alteration
Telephone 'Q��' $10.00 - Residential
(631-) 765-1800 OlPir�,." $25.00 -Non-Residential
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT lajajtj1;30
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for `
C ION PERMIT
RECEIVED
SEPTIC TANK or CESSPOOL
MIN 84
Permit No. 2(0 i'-( g
Fee $ Southold Town Clerk
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APPLICANT NAME: C'� g„(\Q.. C'os \ (-a f-\
APPLICANT ADDRESS: ( p q '(V\2�J le/ J
SEPTIC )( CESSPOOL2(
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: C • 1 Ls CG; Ae CTK1
OWNER MAILING ADDRESS: Al (R_oacl
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OWNER PROPERTY ADDRESS: )O94to (U_
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TELEPHONE NUMBER OF CONTACT PERSON: ---76c-ciia f
TAX MAP NO. : Section Block S Lot ,C). 9
CROSS STREET: t,-)62-,o/
BUILDING PERMIT NUMBER CROSS REFERENCE: 'a lo-1LI
Signature of Applicant
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RECEIVED BY:mak
T. * erk's Office
DATE: