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HomeMy WebLinkAboutCalabrese Joanne ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS ..... 1VrARRIAGE OFFICER · RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN cLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION CONSTRUCTION or ALTERATION PERMIT CESSPOOL or SEPTIC TANK Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631). 7~5-6145 Telephone (631) 765-1800 southoldtown.nor th fork.net Residential ~ $10 J or Non-Residential~ $25__ Applicant Name Applicant Mailing Address Septic Tank or Cesspool Application No. ~-~ Permit No. WY//73 Brief Description of Proposed Construction or Alterahon ~3~- Location oF Proposed Construction/Alteration: Owner of Property: -..To,~ ~ bJE Owner Mailing Address: Ia. o. ~co Owner Property Address: Name and phone number o£ contact person Tax Map No: \~oo Section ~ Block O~ Lot i~,~' Cross Street ~©CKe-~ ~ M~ [NOTE: LOCATION MAP MUST BE SUBMITTED 'WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL Received by: Jignature of Applicant Date O.,~J oz _j t