HomeMy WebLinkAboutSchoof Rolf ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER .......
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Town Hall, 53095 MEn Road
P.O. Box 1179
Southold, New York 11971
... F~X (6~1) 765-6145
Telephone (631) 765-1800
southoldtown.north£ork.net
Residential ~ 5;10 or Non-Residential ~ $25 __ Application No.
Permit No.
Ap p licant Name ~0 t~,,O .r']/..
Applicant Mailing Address ~'?
Septic Tank or Cesspool y~
Brief Description o~P~roposed Construction or Alteration
/
Location of Proposed Construction/Alteratiot3:
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person
Tax Map No: SectiOn ~
?3/ 2
lock ¢rot
Cross Street
NOTE:
CONSTRUCTION REQUIRES SURVEY V~H HEALTH DEPARTMENT
S~gnature of Apphcant
Received by: & ~
!
LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
APPROVAL
Date~