HomeMy WebLinkAboutHoffman James ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
-. ". MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFOI~IATION OFFICER
Town Hall, 53095 Main Road
P,O. Box 1179
Southold, New York 11971
. Fax (631) Y65-6~4.5
Telephone (631) 765-1800
southoldtown.northfork,net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10
Applicant Name
__ or Non-Residential ~ $25 __
Application No. ~
Permit No.
Applicant Mailing Address x.~q ~/~.~r/XtTgl ,,,~'7L
S~tic T~ ~Cesspool__
Brief D~scfiption of Proposed Construction or Altera¢on
Location of Proposed Constmctio~Alteration:
Owner of Prope~y: ~g 6 .. ~
Owner Mailing Address: ~ Q ~IF~ ~ ~
Owner Propeay Address: ~6~ ~a fr~.~
N~c ~d phone number of contact person q ~ ~
Tax Map No: [~ Section ] / ] Block
Cross Street /~V~,. ~F~ ~g
Received by:
Lot
, WITH APPLICATION. NEW
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