HomeMy WebLinkAboutGazza JohnOFFIC~ OF TI~ TOWN ~
TOWN OF SOtJTIIOLD
A. NEVILLE, TOWN CLERK
P.O. BOX
soLrrHOLD, NEW YOKK 11971
Telephone
(63~) 765-1800
Ap¢i~.o. NoBlSt)
Construction
Alteration
$10,00 -Residential V/'
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION ,
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No,
Fee $
APPLICANT NAME:
APPLICANT ADDRESS:
DATE
6-:Z,,,--o3, ,
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
12 -I~- oz j ~ f .r,~f .~ .R Io.:oz-o2/e
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTL~IGTION OR ,ALTERATION': OWNER OF PROPERTY:J~o~'lrl Ga~,Zq
OWNER MAILING ADDRESS:
oWNER PROPERTY ADDRESS:
Or'
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section J ~' Block
CROSS STREET: L6~']'I,C~FI'3 . ,
BUILDING PERMIT NUMBER CROSS REFERENCE:
1650 L~.g~ E~4 Rd,,
RECEIVED BY:~J/%~ '
/ / ' Town Clerk's Office
~Signature o f.~/~l~pl i ca n t
.- ~-' Z~.Oo
Lc 39,Z7
Frank J. Ward,
Licensed Land Suweyor
180 Cuba Hill Road
~'~ = prop.