HomeMy WebLinkAboutSarno JohnOmi:l/OF ~ TOWN CLERK
TOWN OF 80UTHOLD
;TABETH A. N~V~, TOWN ~
P.O. ~x i 179
so~o~, ~w YO~ 11971
Telephone
Application No.3~)
Construction
Alteration
$10.00 -Residential
$25.00 -Non-Residential
TOWN OF SOUTHOLD
ASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME:
DATE
PECONIC CESSPOOL
APPLICANT ADDRESS: P.o. BOX 972
HATTITUCK, NEW YORK 11952'
SEPTIC CESSPOOL ~
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTERATION:
OWNER OF PROPERTY: ~;/'O-/~
OWNER MAILING ADDRESS: ~/~ D~//~
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section i I'J-(iL Block ' (~, LoT /
CROSS STREET: / ~' ~
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY:
DATE:
Town Clerk's Office
JOHN SARNO
1350 SIGSBEE ROAD
MATTITUCK,