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Home My WebLink AboutKudlinski EAPPLICATION Town Hail, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown.northfork.net CONSTRUCTION or ALTERATION PERMIT CESSPOOL or SEPTIC TANK Residential ~ $10 ~or Non-Residential ~ $25 __ Applicant Name /~) ~r ~ Applicant Mailing Address ~7~d) Application No. ~]J_ Permit No. Septic Tank or Cesspool ~ Brief Description of Proposed Construction o~erati~o~ Owner of Property: Owner Mailing Address: Location of Proposed Construction/Alteration: Owner Property Address: Name and phone number of contact person Tax Map No: Section ..~ f-/ Block 7 Cross Street NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL Received by: C~f~ S~gnature of Applicant Date