HomeMy WebLinkAboutInterreal NY Land BI, rir'l~ OF 11~ TOWN C l,g3.~
TOWN Bit 8OIJTIIOLD
JT~BTH A. NRVU! JR, TOWN CL~RK
p.O. BOX 1179
SOUTtlOLD, NI~W YORK 11971
Telephone
(631:) 765-1800
Application No,~ 19 7{,
Construction
Alteration
$10.00 -Residential
$25.00 Non-Residential
TOWN OF SOUTHOLD
F SOUTHOLD WASTEWATER DISPO'SAL DISTRICT
~l~e~/'U CONSTRUCTION or ALTERATION PERMIT
f/~,,//"' SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE~
RECEIVED
~AY 2_8 2003
S0uthold Town Clerk
APPLICANT NAME: PECONIC CESSPOOL
APPLICANT ADDRESS: P.o. Box 972
MATTITUCK, NEW YORK 11952'
SEPTIC CESSPOOL ~
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTERATION:
OWNER OF PROPERTY: -~f./~'~-/c ..~-A~. L /~',~/~I/'~/'~Z
OWNER MAILING ADDRESS: ~7:~" -~
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section //7 , Block O5 Lot
CROSS STREET:~ ~
BUILDING PERMIT NUMBER CROSS REFERENCE:
signature of ~l,~plicant
RECEIVED BY:
T6w'n Clerk's Office
DATE:
HOUSE
ORCHARD
S TRE: T
sURVEY OF
NEWASTUFFOLK SHIF
NEW sUFFOL,
ToWN OF soUTFIC