HomeMy WebLinkAboutSiracusano Louis OFFICE OF TItE TOWN CLERK
TO V~'OF SOUTHOLD
ELIZABETH ~ NEVILLE, TOWN CLERK
PO. BOX 1179
SOUTHOLD. NEW YORK 1'1971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
Applicfition No.
Construction
Alteration
$I0.00 -Residential /~
$25.00 -Non-Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION .or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME:
APPLICANT ADDRESS:
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:
OWNER ~A,U~O Aoo~ss:
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.~ Sec.on 71 B,ock I Lot
BUILDING PERMIT NUMBER CROSS REFERENCE:
SignatUre of Applicant
RECEIVED BY: (~),. ~
/Town Clerk's Office
DATE: ~//~ ~--'~ .
SUP-.k/tEY OF= PP-,.OPEP-.."F'¢
51TUATE."
TOk,~N OF 50U"EHOL_.P
.St.,"r-F',-OLF---.. COUNT'C, NC'
N
COUNTy W E
~H10: 59
~F APPROVAL
JOFfl'q C. EHLERS LAND