HomeMy WebLinkAboutCorneell 40,01
' Town Hall, 53095 Main Road
o- `�, P.O. Box 1179
'_49.
01 ��®�! Southold, New York 11971
JUDITH T.TERRY 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. 1223-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CORNWELL, MARGARET M.
Mailing Address 1 500 WEST COVE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 115 HAYWATERS ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6159
.Tax Map No. section 111 .00 block 1 lot 6.000
Cross Street WEST COVE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK °C;q6kA,""'--
Town of Southold t- Application No. /
Judith T. Terry, Town Clerk ,,Ael
Town Hall, 53095 plain Road '' aau � $10.00 - Residential l
P. O. Box 1179 un `.
Southold, New York 11971 P l'� to $25.00 - Non-Residential
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Telephone -‘.'"I 44 It
`a�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE A flit 9g7
OWNER NAME: 2O )1(IASiE Lt. MARC-f-) (0:2 T
• OWNER MAILING ADDRESS: S00 Rs r COVE ' D
Lst Ta /--( �� w, V ° it 93._S--
OWNER PROPERTY ADDRESS: // 14/4-7EF RS. ROA D
r
OWNER TELEPHONE NUMBER: 73 -- 6 /��?
TAX MAP NO. : Section /f// // Block / Lot
CROSS STREET: WE
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / --New a.. —Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 77"/""7?
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.)
tt I i ) LA fiC�'�
�fi_ � 4Zu
Signature of Applicant
RECEIVED BY: fIl . )* I► •
own Clerk's Office
DATE: CS 1p \C6C1
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