HomeMy WebLinkAboutCassara Ronald Ol~I(~ OF ~[/d~ TOWN CLERIi
TOWN OF ~OIITHOLD
D'AB Eq'H A. NEVILLE, TOWN CI2RK
P.O- BOX i 179
SO(,rI'HOLD~ NEW YORK 1197!
Telephone
(63~) 765-1800
Applicatlon No,
Construction
Alteration
$10.00 - ReSidential
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
~or
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME: ~U0/{~ ~t
APPLICANT ADDRESS: ~3~
SEPTIC ~ CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION ~/~
~/c T~ ~o ~r~r~ ~r~d ~ / ~ ~ ~ff~ '
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:' OWNER OF PROPERTY: ~/~)
OWNER MA'L'NO ADDRESS: ~/~20Z~/OU~?~'
OWNER PROPERTY ADDRESS: ~O/~ ~O~
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section ~3 Block O~ Lot
CROSS STREET: ~/~ ~0~ ~ ~OU~
RECEIVED BY:~
DATE: 111~)/0T"~wn Clerk's Office
'Applicant '
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