HomeMy WebLinkAboutPetikas Theodore ELIZABETH A. NEVILLE
TOWN CLERK
REGISTHAR OF VITAL STATISTICS
....... MARRIAGE OFFIGER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
.... .Fax (63~). 765-6145 .
Telephone (631) 765-1800
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 L///or Non-Residential ~ $25 __
Application No.
Permit No.
Applicant Name ~ ~t;~) ~ 0tr~-~
Applicant Mailing Address 9~- .~JF~d-~U/J[- ~
Septic Tank k//or Cesspool ~'~tL~"~4'_ ~-'
Brief Description of Proposed Construction or Aheration_ ~,J~J
Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person ¢~,,/~ ~t~ [~.~1/I ~'
TaxMapNo: Section -ffO Block ~:; Lot ar/(::,
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY ~VITH HEALTH DEPARTM[ENT APPROVAL
Signature of Applicant Date
Received by: ~ ~