HomeMy WebLinkAboutCornell (2) a'. ,
•
49,,,,,-0%-oVf air
r�1 Town Hall, 53095 Main Road
izst
P.O. Box 1179
_ ��®iI/ Southold, New York 11971
JUDITH T.TERRY A ��/ FAX(516)765-1823
����/ TELEPHONE(516)765-1801
TOWN CLERK
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. 995-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CORNELL, MAYBELLE
Mailing Address 1 BOX 386
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 MAIN ROAD
Property Address 2
City'St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-1359
Tax Map No. section 31 .00 block ' 4 lot 10.000
Cross Street STARS ROAD
Date Of Last Pump Out 8/12/87
Issue Date: 1/27/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK c3\\VH (
Town of Southold ® �; ��4 �G Application No. ( 7T
Judith T. Terry, Town Clerk r� :a. 4i, 1.`\
Town Hall, 53095 Main Road - ` # u M :'� f Residential
P. O. Box 1179 cn hzi ��' Non-Residential
Southold, New York 11971 O� '�`�
Telephone off` # '/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 11/n23lvq'
OWNER NAME: m n v (lP , Covnel l
OWNER MAILING ADDRESS: Gpx �� (-� 7 Cc�S nOcATI'on 1/931
OWNER PROPERTY ADDRESS: (nQ ( n("N ECN Y) ;O( 11939
OWNER TELEPHONE NUMBER: (5(g) Li ?? - J 3 59 {
TAX MAP NO. : Section 3 , Block Lot / C�
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ?AZ—
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.)
y _ .ignature of Applicant
-
RECEIVED BY:
G Town Clerk's Office
DATE: ��-�
pc _
Nur
t
t otAf-
r V 1 r A
le
`n , �-
04-
J
I
r . f
road_