HomeMy WebLinkAboutFirst Baptist Church ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORIVIATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
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 ~'{t~'. ~)~-~t-ff~ ~
Applicant Mailing Address {9./). /~.~
Septic Tank or Cesspool J
Brief Description of Proposed Construction or Alteration /qtuJ
Location of Proposed Construction/Alteration:
OwnerofProperty: '~. 'ff~'f ~)O.d~l~c ~J, III4'C.~ 0'//' ~~.~.~.~.
Owner Mailing Address: ~- ~. ~ ~-~ ' ~ 0
OwnereropenyAd&ess: 15q 5 %8
J ~ I. ~ (~0 ~&~-tq~7 ~
Nme ~d phone number of contact person J~t~ ~ (~) ~qK- ~ ~
Tax Map No: Section ] O I Block { ~t I~ ~
Cross Street Al~h5 ~ ~ ~ ~ ~
NOTE: LOCATION ~P MUST BE SUBMITTED WIT~ APPLICATION. NEW
CONSTR~CTION ~QUI~S SURVEY WITH HE~TH DEPARTMENT APPROV~
Si~ature of Applicant Date
Received by:
t
,.,?
APPROVED BY
~A,N NING BOARD
OF SOUTHOLD
JFFOLK
CALL
MUST BE INSPECTED 1
DEPT. Of HEALTH SE
48 HOURS IN ADVA
INSPECTION IS).
OF HEALTH
,' ~..~ APPROVED FOR CONSTRUCTION ONL
granted for the conslm~ion of
Code and i~ not a
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