HomeMy WebLinkAboutHalsey Cynthia ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
. ' .... MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICEH
~ SOUTHOLD WASTEWATER DISTRICT
/~ APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
·. Fax.(63.1) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
Residential ~ $10 ~" or Non-Residential ~ $25 __
Application No. C~/~ ~')
Permit No.
Applicant N ame/-~-'z~(~::,
Applicant Mailing Address ~'z'~ '~" z~'---~'-~ ~-~
Septic Ta~ or Cesspool /
BriefDescriplion of Proposed Construction or Alteration
~cation otProposcd Const~ctio~Alteration:
Ow. r ot
Owner Mailing Address: ~
Owner Property Address:._~-.-.~-
Name and phone number of contact person ~-~dl/d' ~,,'~/f- .:~'d. --
Tax Map No: Section ,/C:>~9t52 Block C>~,~' Lot
Cross Street .,~ o,2.~--
NOTE: LOCATION MAP MUST BE SUBMITTED V~7ITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of Applicant Date
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Received by: