HomeMy WebLinkAboutSzczepankowski David OFFIre OF ~ TOWN ~
TOWN OF ~OUTIIOLD
17ABI~TH A. NIIVII~. TOWN CLERIC
p.O. BOX 1179
$OUTItOLD, NI/W yORK 11971
Telephone
(63t) 765-1800
Application No.~/~
Construction
Alteration
$I0,00 -Residential ~
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
~~~/~)~"'- APPLICATIONfor
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME:
DATE
PECONIC CESSPOOL
APPLICANT ADDRESS: P.o. BOX 972
MATTITUCK, NEW YORK 11952'
SEPTIC CESSPOOL ~
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTERATION:
OWNER OF PROPERTY:~/.~/~"/
OWNER MAILING ADDRESS:~~
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section C~75 Block /~)'~') Lot '/~)~ /
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature pplicant
RECEIVED BY:
Town Clerk's Office
DATE: