HomeMy WebLinkAboutNeuman Helen ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFF~[C~R ~_
FREEDOM OF INFORMAj~ION ~.~ .
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.4~ /- ~ .~...,tf' ~ ItJO'FFICE OF THE TOWN CLERK
/ · '.,'/'"/~_ ,"~:'~/- TOWN OF SOUTHOLD
~ v ' ~ SOUTHOLD WASTEWATER DISTRICT
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nor thfork.net
Residential ~ $10 or
Applicant Name
Applicant Mailing Address
Non-Residential ~ $25 __ Application No.
Permit No.
Septic Tank ,or Cesspool
Brief Description o~~.}ion or Alteration
/
Location of Proposed Construction/Alteration:
Owner of Property: ~//~,'-/~!'-
Owner Mailing Address:
Owner Property Address:
Name and phone number ofcontact person 7dfl~- ~ 7..~6r-dfl
Tax Map No: Section ~/0 Block fT-- Lot
Cross Street
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Received by: ~'~ ~l],[O~J
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Si/gnature of Applicant Date