HomeMy WebLinkAboutHoell Steven ELIZABETH A. NEVILLE
TOWN CLERK
REGISTHAR OF VITAL STATISTICS
· - ' · MARRIAGE OI*FICER ' ·
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hail, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
· . Fa~x.(6~.l) 765-61~5. .......
Telephone (631) 765-1800
southoldtown.nor~hfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 V//or Non-Residential ~ $25 __
Application No.~ ~' [ ~
Permit No.
Applicant Mailing Address ~1._..~<:~ ~)L.~"'~(~3 ~
Septic Tank V~ or Cesspool ~'/~' ~'
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner ofProperty: ~"~:iiE~l~.¥--~ ~ , ¥-~..
Owner Mailing Address:li:).-'q~ (~C__q~-~--Q) cl.'~& '~k.~ }tq~ ~
OwnerPrope~yAddress'a~q ~t tx',~l~} ~th~l
N~e ~d phone number of contact person ~0~ ~, ~%~ ~ ~
tax Map No:l~O~ Section ~ ~ Block ~ ~ Lot ~, g
/NOTE: LOCATION M~ MUST BE SUBMITTED WITH APPLICATION.
CONSTRUCTION ~QUI~S SURVEY WITH HEALTH DEPARTMENT APPROV~
Received by: ~
~*7"gnat~rre of Applicant ~ ~at~'
no polob e
143.00'
.75'