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ELIA. Town Hall, 63095 Main Road
ZABETH NEVIIXE
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.not
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 or Non-Residential @$25 Application No.
Permit No.
Applicant Name
Applicant Mailing Address X3 C)
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Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteratioti. 3
Location of Proposed Construction/Alteration:
Owner of Property: F'F—i V--'C->1.......
Owner Mailing Address: -:L3
Owner Property ...................
Name and phone number of contact person
Tax Map No: Section 31.00( Block of,ao Lot 00-5.006
Cross Street E—V 00(
R,M- k-L,
NOTE: LOCATION MAP MUST BESUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEAI TH. DEPARTMENT APPROVAL
............
Signature of Applicant ............... Ce
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Received by ........
RMI AOR APPROVAL OF CONSTRUMON FOR
[ SINGLE `AMID RESIDENCIEONiLY
JD ?_ � . ' - tom;
APPROVED
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SCTM# gj _ = E
1000-31-02-19
VACANT EX? R_-- 1-3 D A`-2 '= f 4 jPROV