HomeMy WebLinkAboutBruno Nicholas ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
...... MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFOP~f~ATION OFFICER
Town Hail, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (637) 785-6145 ....
Telephone (631) 765-1800
southaidtown.northfork.net
Residential ~ $10 o~r Non-Residential ~ $25 pAeppr~lii~ ~.n No.
Applicant Name ~\1C-~O[ tls
Applicant Mailing Address 4 t~ ~ /~'~ 7_
Septic Tank or Cesspool ~
Brief Description of Proposed Construction or Alteration
Location of Proposed Constmctio~Alteration:
Owner of Property: N ~c~ 0 [~ ~, [
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person ~ '~ ~/~- ,~, q ~/~ q'd,~'t~
Tax Map No: [0~ Section ~& Block ( Lot ~
Cross Street ~ ~
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION ~QUI~S SURVEY WITH HEALTH DEPARTMENT APPROV~
Signature of Applicant
Date
N '79' 45' SO"
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