HomeMy WebLinkAboutWolzcok JohnOFl~r~ OF '~E TOWN
TOWN Ol~ ~OUTHOLD
P.O. BOX 1179
Telephone
(63'1) 765-1800
Application No.
Construction
Alteration
$10,00 -Residential
$25,00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRIC,.~/~ .~'7--~
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
APPLICANT NAME:
PECONIC
DATE
CESSPOOL
APPLICANT ADDRESS: p.o. BOX 972
MATTITUCK, NEW YORK I 1952'
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONS. TRUCTION OIR ALTERATLQN
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALT~iRATION:
.OWNER OF PROPERTY: ~"~ ~V0/Z~._ggi~"'
OWNER MAILING ADDRESS: .---~>~-- ~} ~ %d~
OWNER PROPERTY ADDRESS: /~'~ ~$~e ~&
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section I~'lt B~oc~, O I
CROSS STREET: ./~--~
BUILDING PERMIT NUMBER CROSS REFERENCE:
/175
RECEIVED BY: T~~
DATE:
Signature of ~plicaht
JOHN WOLZCOK
1880 $IGSBEE ROAD
MATTITUCK