HomeMy WebLinkAboutCornwell i
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\ `Town Hall, 53095 Main Road
�® �`� P.O. Box 1179
® `` ' �® o, Southold, New York 11971
JUDITH T.TERRY 1 rl��'' TELEPHONE
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. 697-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner CORNWELL, CLIFFORD G.
Mailing Address 1 500 WEST COVE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 500 WEST COVE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6159
Tax Map No. section 111. 00 block 2 lot 8. 100
Cross Street HAYWATER ROAD
Date Of Last Pump Out 0/00/85
Issue Date: 5/12/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK OF it
Town of Southold N' sC -4i% Application No.� 9' 7
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road `' �� Residential
P. O. Box 1179 c-" VO. ' .` Non-Residential
Southold, New York 11971 O0 4A,
Telephone _
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE -5-1/J ire
OWNER NAME: Ci,' oi-o'- 6 Co
OWNER MAILING ADDRESS: 52555 p@,
Citi-f 1 -F, 6N. a• I —
1
OWNER PROPERTY ADDRESS: As-
OWNER
sOWNER TELEPHONE NUMBER:(6/7) -7 3 - 6
TAX MAP NO. : Section 1/ 1 Block, `�c�'. / Lot
CROSS STREET: f/7-y bv'A 4 i /fQ rop.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: AislL _$ / /`cf-C
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.)
Signature of Applicant
RECEIVED BYL c---Q (�
Town Clerk's Office
DATE: - i7 S. 6
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