HomeMy WebLinkAboutTintle William ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
F~..(~3 ~).~65~6145
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 or Non-Residential
Permit No.
Applicant Name L~/tOf~ /"/'Z)Iq~Zg~. ~f
Applic~t Mailing Ad~;;ss ~2/
Septic T~ ~ Cesspool ~'
Bric,Description q f Propgsed Con~tm~tion or Alteration~O~
~cation of Proposed Constmctio~Alteration:
Owner Mailing Address:
Owner Property Address: /
Name and phone number of contact person ~/~ ~ ~/'/")6~//~/gt.~gc:~2"'~03c/'
Tax MapNo: .1 Section~O Block ~ ~ ~t O/7
Cross Street ~~~
NOTE: LOCATION MAP MUST BE ~UBM~TED WITH APPLICATION. NEW
CONSTRUCTION ~QUI~S SURVEY WITH HE~TH DEPARTMENT APPROV~
~ate t
S~e of Applicant
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