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JUDITH T.TERRY �� _ < • - Town Hall, 53095 Main Road
TOWN CLERK ; y ,e4
P.O. Box 1179
•s• Southold,New York 11971
REGISTRAR OF VITAL STATISTICS V`
O Fax(516) 765-1823
MARRIAGE OFFICER iff , '.,
RECORDS MANAGEMENT OFFICER : .� * `/I I
'I,i Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3436-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner COSIMANO, BERNARD
Mailing Address 1 845 WATERSEDGE WAY
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 845 WATERSEDGE WAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2174
Tax Map No. section 88.00 block 5 lot 63.000
Cross Street BAY HAVEN ROAD
Issue Date: 2/21/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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` OFFICE OF THE TOWN CLERK ����FFO/`A`CQ�"
Town of Southold , �� Application No. V54
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 8 $10.00 - Residential
P. O. Box 1179 cn _` i ;' $25.00 - Non-Residential
Southold, New York 11971 O �`
Telephone fOI It%e4)
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
. Fee $
DATE o2-/z- 9 f'
OWNER NAME: - E/Q/Ul & 0 'J®S/ 11400
OWNER MAILING ADDRESS: g7s tLJ 7 sb6 ., W1
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OWNER PROPERTY ADDRESS: g`1/5" u 7- . Wft/
s'oarAtekb i►Y, .
OWNER TELEPHONE NUMBER: -.574'— '/t4S`'oil7
TAX MAP NO. : Sectio :=r 4 7 Zg Block 5 Lot A3
CROSS STREET: -1819-Y f/4-vw Riog)
TYPE OF SYSTEM: Septic Tank. New Existing V
Cesspool New Existing
Residential V Non-Residential
•
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.)
Ark-AfG04, 421:U/111--,///-Z)
Signature of Applicant
RECEIVED BY: /V/H'' '
' Town Clerks Office- .
DATE: - 4.,//&/ 6