HomeMy WebLinkAboutDaly Maura OFF~(~ OF ~ ~OWN
TOWN OF ~O01~OLD
PJ ]7~ A. NBVI~ ~ ~ TOWN ~
P.O. ~X i 1~
~0~, ~W YO~ 11971
Telephone
(63t) 765-I
Application No.
C~3~ucu on
$10.00 ~
TOWN OF SOUTHOLD
tOLD WASTEWATER DISPOSAL DISTRICT
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
DATE
APPLICANT NAME: PECONIC CESSPOOL
APPLICANT ADDRESS:' P. O. BOX 972
MATTITUCK, NEW YORK 11952'
SEPTIC CESSPOOL ~,-'/,
DESCRIPTION OF PROPOSED CONSTRUCTIO~N OR ALTERATION
LOCATION MAP:
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTF..RATION:
OWNER OF PROPERTY: '~/~~_~ .~
OWNER MAILING ADDRESS:
Must be attached hereto before permit may be issued.
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section J~ Block ~ Lot /
CROSS STREET: ~ ~
BUILDING PERMIT NUMBER CROSS REFERENCE:
5ignatur(, of ~l~lShcant
RECEIVED
/ -/Town/Clerk's Office