HomeMy WebLinkAboutMcCullough, H Norman r
OFFICE OF THE TOWN CLERK C4FOGrt►
Town of Southold &G
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179 tri
Southold, New York 11971
Telephone "�l [ ,„„
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 186 Residential X —
Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
NAME: H. Norman McCullough
ADDRESS: 510 Main Street -.--
Greenport, New York 11944 ---
DESCRIPTION OF PROPOSED CONSTRUCTION or ALTERATION
New Single Family Dwelling with Sanitary System •
APPROVED -as submitted ----
LOCATION OF PROPOSED CONSTRUCTION or ALTERATION:
OWNER OF PROPERTY: H. Norman McCullough
OWNER MAILING ADDRESS: 510 Main Street �.
Greenport, New York 111944
OWNER PROPERTY ADDRESS: Cox Lane
Cutchogue, New YOrk
TAX MAP NO. : Section 84 Block 1 Lot 3
CROSS STREET: Oregon Road
BUILDING PERMIT NUMBER CROSS REFERENCE:
Judith T. Terr
Southold Town Clerk
DATE : June 23, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold
Application No./"
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road Construction
P. O. Box 1179
Southold, New York 11971 Alteration
Telephone Residential \IC
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION .
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. / '
Fee .$
DATE (,�//f/��
APPLICANT NAME: ft. )JQf c ,,,, J`kCCiAA 6k.N
APPLICANT ADDRESS: 5 \ D ic_,,i_ n jc _
C.-,c.e_�,reA , \( i ( 9c(L(
SEPTIC (PC CESSPOOL l0
DESCRIPTION OF
PROPOSED CONSTRUCTION OR ALTERATION
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: A.t, ,tip-.,„„,,;, e C Lakcst.A. <e _
OWNER MAILING ADDRESS: _>- 1c) )Acj ,,, 5 V ,
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OWNER PROPERTY ADDRESS: rack L"
PI A,,, ,e_._ A ) i (cf 3
TELEPHONE NUMBER OF CONTACT PERSON: (9 77 r a_C, (I,
TAX MAP NO. : Section `-L4 Block I Lot 3
CROSS STREET: CSX (_,,t 4om„ff„,
le-9
BUILDING PERMIT NUMBER CROSS REFERENCE: i l
ignature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: •
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SUFFOLK CO. HEALTH DEPT. APPROyAL
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- SA R R (VAc-AN 1" ,'
giN /LE YEARS FROM DATE
OF APPROVAL
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iV ( �(, ± CO � rJ • t(7 vA_ STATEMENT OF INTENT •
N ` �� N THE WATER SUPPLY AND SEWAGE DISPOSAL
4� G5- --- - - -- --'_ _ - _ - _ - ��- _ _ r _ - SYSTEMS FOR THIS RESIDENCE WILL
CONFORM TO THE' STANDARDS OF THE
(,; .i.( r 11J ► SUFFOLK C r/ DEPT. OF HEALTH SERVICES.
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SUFFOLK COUNTY DEPT. OF HEALTH
SERVICES - FOR APPROVAL OF
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1- ! 0 t1' _ SUFFOLK CO. TAX MAP DESIGNATION:
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ACV 1000 �'f� j
� � - OWNERS ADD�E��S:"
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LICENSED LAND SURVEYORS -11 �Qt iiU`
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GREENPORT 'NEW YORK
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