HomeMy WebLinkAboutDebruin WilliamOI~1CR OF TI~ I'OWN CL~RK
TOWN OF ~OtJ'IIlOLD
pi 17~BI~TIt A. NllV~! ! Il; TOWN CLERK
P.O. BOX 1179
$OUTHOLD, N~W YORE 11971
Telephone
(631) 765-1800
Application No.
Construction
Alteration
$10.00 -Residential
$25.00 - Non-Residential
Permit No.
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
RECEIVED
JUN
Southold Town Clerk
Fee '$
DATE
APPLICANT NAME:
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.
LOCATION OF PROPOSED CONST~RUCTION OR ALTERATION:~
OWNER OF PROPERTV:~ ' ~-~~.~
OWNER MAILING ADr:,RESS: ~,,~ .~'-~-~'"~~ .~
OWNER PROPERTY ADDRESS: ~~-
TELEPHONE NUMBER OF CONTACT PERSON: ~~
TAX MAP NO.: Section /0 ~ Block ~ Lot /~
cross STREET:__
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Apl~ricant
RECEIVED BY:
DATE:
To,wn Clerk's Office
WILLIAM DE BRUIN
2570 PINE TREE ROAD
CUTCHOGUE