HomeMy WebLinkAboutJaswal Saroj ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
· ' '. · MARRIAGE OFFICER · . .. '-
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
-. -.~g~- .~ o~F~ICEOFTHETOVfN CLERK
a
~ ~- t - APPLICATION
~ CONSTRUCTION or ~TE~TION PE~IT
~ CESSPOOL or SEPTIC T~K
Residential ~ $10 or Non-Residential ~ $25 __
P.O. Box 1179
Southold, New York 11971
Fa~ (63D 76~-6145
Telephone (631) 765-1800
southoldtown.northfork.net
Application N .o~r(~/~
Permit No.
Applicant Name
Applicant Mailing Address
Septic Tank or Cesspool
BriefDescriI]~on of Pro~..c~ed Constmstion or Alteration
/
Location of Proposed Construction/Alteration:
Owner of Property: ~'2/~
Owner Mailing Address:
Owner Property Address:
N~c ~d phone number of contact person
Tax Map No: Section
Cross Street
NOTE: LOCATION ~P MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION ~QUI~S SURVEY WITH HEALTH DEPARTMENT APPROVAL
Si~ature of Applic~t Date
Received by: