HomeMy WebLinkAboutVazquez Don OFTICE OF ~ TOW[4 CLE,q.K
TO *,',2~ OF SOUTHOLD
~.L~ ;~,~ ~. NEVi, TOWN C~RK
P.O. BOX 1179
SOb~O~, h~W YORE 1 !77~
Telephone
Application N o, .~___.~
Construction
Alteration
-Residential
765- 1801 $25, O0 - Nbn-ResidentiaJ
f ~O TOWN OF SOUTHQLD
~S~.,zi~ SOUTHOLD \'IASTEWATER DISPOSAL DISTRICT
SEPTIC TANK or CESSPOOL
Permit No,
Fee $
DATE.
APPLICANT NAME:
APPLICANT ADDRESS:
-'::...'..?3;'p 0;;B6× 361
.:3";. Wa d ili~B iv e rFNY-fl~g¢.
SEPTIC~,'~ CESSPOO~
DESCRIPTION OF F;ROPOsED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit' may be Issued,
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION;'
TELEPHONE NUMBER OF CONTACT PERSON:
BUILDING PERMIT NUMBER CROSS REFERENCE;
RECEIVED BY:
DATE: