HomeMy WebLinkAboutLepkuecher Joseph ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER · '
i~ECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax 5631)7~5-6145.
Telephone (631) 765-1800
southaldtown.northfork.net
OFFICE OF' THE ToWN CLERK'
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
Residential ~ $10 /
Applicant Name ¢ c~'~ k
Applicant Mailing Address
CESSPOOL or SEPTIC TANK
Non-Residential ~ $25 __
?. o. /-5 x
Septic Tank or Cesspool-/
Brief Description of Proposed Construction or Alteration._
Application No. ~ / (~>D~'
Permit No.
I/'q
Location of Proposed Construction/Alteration:
Owner of Property: ~/_)qa_ ~
Owner Mailing Address: ~ C>
Owner Property Address: ~/~
Name and phone number ofcontact person C~h~/IL5 ~rm~ 5 ~/
Tax Map No: Section
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION ~QUI~S SURVE~ WITH H~ALT~ DEPARTMENT APPROVAL
(~,atur~ of Ap~li:a~ Date
Received by:
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A[de~ W, Young, P.E. · L.$. (1908-1994)
Howo,~-d If. Yo~/J, Lo~d S~veyo~
Thomas C. 1fotpe~t. Profess~o~,~[ E~xginee~'
l~obe~t C. Twst, A~el~itect
HEALTH DEPARTMENT
NOTE
TOTAL AREA -- 35.7860 ACRES
· SURVEYOR'S CERTIFICATION
WE HEREBY CERTIFY TO ,.JOBIEF~H LEEIKILIIECH£R THAT
THIS SURVEY WAS PREPARED IN ACCORDANCE ~TH THE CODE OF
PRACTICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK STATE
ASSOCIATION OF PROFESSIONAL LAND SURVEYORS.
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