HomeMy WebLinkAboutCooke Mk'
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pk4 � Town Hall, 53095 Main Road
VIP� s N- .4 P.O. Box 1179
Southold New York 11971
JUDITH T.TERRY o FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1241-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COOKE, JANE WHITE
Mailing Address 1 10245 NASSAU POINT ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 10245 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6006
Tax Map No. section 119.00 block 1 lot 12.000
Cross Street WUNNEWETA ROAD
Date Of Last Pump Out 0/00/65
Issue Date: 9/06/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK es
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Town of Southold - ���f C 14/
�, Q '�, Application No. �O `� i!
Judith T. Terry, Town Clerk �` z��= .
~ ' = 1
Town Hall, 53095 Main Road ,� -;: Residential
P. O. Box 1179 �' ` ni ;' Non-Residential
Southold, New York 11971 OO .' ` �0���`�
Telephone = .( Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
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OWNER NAME: � �e W (A (T7II -C
OWNER MAILING ADDRESS: ( D_.1+6- jtJüAJ* /41, i ?\; Rd
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its (tn�� �Q �l ( ( q °35-
OWNER PROPERTY ADDRESS:_-(t,it P
OWNER TELEPHONE NUMBER: S4 ( Q
• TAX MAP NO. : Section //9. Block / Lot
CROSS STREET:
YS Septic Tank "New Existing
OF SYSTEM:T S p
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 19 (Q -�
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.)
es
Signature o Applicant
Np
RECEIVED BY:
Town Clerk's Office
DATE: ® Q ,`�j
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