HomeMy WebLinkAboutCooper Of
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Town Hall, 53095 Main Road
izPP.O. Box 1179
v \cizo Southold, New York 11971
JUDITH T.TERRY re . io
" TELEPHONE
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TOWN CLERK �<��/��� (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. 931-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COOPER, SHERWOOD
Mailing Address 1 P. O. BOX 108
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 5500 NEW SUFFOLK ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6631
Tax Map No. section 117.00 block 2 lot 19.000
Cross Street TUTH I LL ROAD
Date Of Last Pump Out 0/00/85
Issue Date: 11/28/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK S\\FFU(,r '=
Town of Southold s CQ ' Application No.
Judith T. Terry, Town Clerk .,
53095 Main Road Residential
Town Hall, c $� ':,
p. O. Box 1179 to `•. � { i Non-Residential
Southold, New York 11971 Off' '' a P:f:
Telephone
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(516) 765-1801
TOWN OF SOUTHOLD
MEW '
NO SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Ton mg Southold APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
--Fee $ .
DATE
OWNER NAME: 5, � D Coo
OWNER MAILING ADDRESS: PQ 6 /Os'
OWNER PROPERTY ADDRESS:`,$S=ao
OWNER TELEPHONE NUMBER: 7354-C6-3
TAX MAP NO. : Section //'7 Block Lot /9
CROSS STREET: -
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing I�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /,1:3--
LOCATION
911'.5'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.)
'72V V'JAL� Jo�
Signature of App icant
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RECEIVED BY:
h, , ,,zi,•wn Clerk's Office
DATE: NOV 8 T
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