HomeMy WebLinkAboutClausen Gustave (2) ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
........... MARRIAGE.OFFICER ....
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (6B1) 765-6!45 .. .
Telephone (631) 765-1800
southoldtown.northfork.net
RECEIVED
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
JUN 2 0 2003
Southold Town Clerk
Residential ~ $10 /or Non-Residential ~ $25 __
Application No.~ [ ~
Permit No.
ApplicantName'~[-"~0-,~) ~ {N~.,[~/~ O~c[,~_._
Applic~t Mailing Ad,ess ~0 ~ ~ [ ~ ~ ~
Septic Ta~ ~r Cesspool ~
Brief Description of Proposed Construction or Alteration
Location of Proposed Constmctio~Alteration:
O~erofmrope~y: ~~) ~e~
Owner Mailing Address: ~~ h ~V
Owner Prope~y Address:
Name and phone number of contact person
TaxmapNo: Section [1~0o Block
Cross Street ~,0,5. ~ -q- ~nt-,~O, 0.~c~.. ~_~
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signatur cant Date
Received by: