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HomeMy WebLinkAboutCarpenter Pat ELIZABETH A. NEVILLE ff~- ~~ REGISTRAR OF VITAL STATISTICS ~ ~ 1~ ~ ~-~ ~ FREEDOM OF INFOR~TION OFFICER/]~__ '~ ~ ~ ' ,J , J v.....~E OF THE TOWN CLERK ~ APPLICATION Residential ~ $10 ~or Non-Residential ~ $25 ~ Applicant Mailing Address 27[¢ Septic Tank or Cesspool ~( Brief Description of Proposed Construction or Alteration Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown.northfork.net Application No. ,~o2, ~ ~ Permit No. Location of Proposed Constmctio~.A~pration: Owner of Property: Owner Mailing Address: Owner Property Address: Name and phone number of contact person Tax Map No: Section ~o~ Cross Street 70 T - ~3oo ,DOCe~- Block ~ Lot .2/ NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURVfi,~ WITH HEALTH DEPARTMENT APPROVAL Signature of Applicant Date Received by: / I 1 !