HomeMy WebLinkAboutKoehler Rudolph ELIZABETH A.~ f~'~~'~ Town Hall, 53095 MEn ~ad
TO~~ } ~ ~~ ~ P.O. Box 1179
REGIST~ ~TISTICS ] ~ ~ ~~ ~ ~ Southold, New York 11971
~GE OFFIC~ / ~-~~~ F~ (631) 765-6145
~C~AGEMENT OFFICER / ~d~~ Telephone (631) 765-1800
/ APPLICATION ~:
Residential ~ $10 ~on-Residential ~ $25 ~ Application No.
Pe~it No.
Applic~t Nme ~~
Applic~t Mailing Address ~ ~ ~~
Septic T~ or Cesspool ~
Brief Deception of Proposed Construction or Alteration ~// ~
Location of Proposed Constmctio~Alteration:
Owner of Prope~y: ~
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person ~'d~./J
Tax Map No: Section '~ Block
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of Applicant Date
Received by: '
N