HomeMy WebLinkAboutPeyton Just oFYlC~ OF ~ TOWN
TO~q OF ~OTJTHOLD
vJ JTABI/Tlt A. NBVILLI/. TOWN CLIJRK
P.O. BOX i
$OUTHOLD, NBW YORK 11971
A,,,, at,on No.3f??
Construction
Alteration
$10.00 -Residential
Telephone
(63t) 765~-1800 ~'/~ $25.00 -Non-Residential.
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee ~.
APPLICANT NAME:
DATE
PECONIC CESSPOOL
APPLICANT ADDRESS: P. o, Box 972
MATTITUCK, ,NEW YORK 11952·
SEPTIC CESSPOOL ~
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS:
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTERATION:
· OWNER OF PROPERTY: ,~"/'~ .,~,~,~"~,. ,~_,~,~.~ ~O~p ~OST
TELEPHONE NUMBER OF CONTACT PERSON
TAX MAP NO.: Section )/~' Block ~:;~'" Lot
CROSS STREET: /~ .~ ~
BUILDING PERMIT NUA?r' ~ROSs REFErEe! ~:
RECEIVED
JU'~
RECEIVE~ BY; -
Town Clerk's Office
DATE: Southold Town Clerk
~ignature of Appli~Jmt
ELIZABETH PE~TON & ANTHONY JUST
195 VILLAGE LANE
ORIENT