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1'0 \~1~ OF sotrr~OLD
Telephone
Application No.~_.
Constructibn
AIteradon
$10,00 -Residential
$25,00 - N0n-Residential.
TOWN OF SOUTHOLD
SOUTHOLD \VASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No,
Fee ~
DATE
APPLICANT NAME:
APPLICANT ADDRESS:
SEPTIC?~ CESSPOOL /~
DESCRIPTION OF F~ROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit' may be Issued,
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:'
OWNER MAICING ADDRESS:
R,-C~. I VE D BY:
I T~wn Clerk's Office
'-.
D,-,, T :.
OI'/N£R PROPERTY ADDRESS: A/~tO ~ i~z'O ~ . .
TELEPHONE NUMBER OF CONTACT PERSON:·
c~oss sz~z: LA~b G~ ~',A.~ .,
LOT ARCr.:A-=4(~,iO00'~ aq: ft:. ~: :. · NOTE. LoCATioN OF Al}JOINERS WELLS ~; CES'SPOOLS
F. FL F. LEV. 20.5 ,, '
GAR, E1.EV.= 18.5 BY OTHERS & ARE NOTG ARANI'-c. ED. ~ ,
· SUI
''OLI'( COUNTY
! 2003,rJIN ! ~ ;r AHIO 25
LJ ~
~ . - . . 'PLEA N6 E : -
SE T
M~mmu~ distance between well
and ce~$p6ol is to be 150 feet.
~~~ ~~.~ JOB No;'01-2~ F~U No. ~DS
: ' ~D FOR
~~m~~m.~m~ LOT NUMB~ 2g
m~ ~ ~ ~. ' , ~ OF ~DS END AT ~1~ POI~
~mK~jm~m~.~ S~A~D AT ORIE~ POI~
~ 1" = ~' DA~'9-4-2001
R~ ~ NO, 5909 ~ 5-3-1973
CE~IRED ONLY TO:
~ .' ' T~ ~ No. (~ ONL~ 100~15~9--t.29 DISK 500
- ub~ OR. P.c.
- -- ' . ~ROLD F. T NC
~ ~ ~~ ~66 WADING RNER-~NORN~ YORK .1'92RD' WADIN~'RNER.
' ' ~ ,., N.Y L~. ~. 048992 631--929--~695
~ROLD F. T~HO~ ~R. ,/,' PENN, LC No 21~,-E