HomeMy WebLinkAboutHassildine Edward OFFIC~ OF T~ ~OW/~ ~
TOWN OF ~OLS'HOI,D
·
P.O. l~OX
~OUTHOLD, NEW yORK
Telephone
(63 ~:) 765-1800
TOWN OF SOUTHOLD
Application
ConstructiOn
Alteration ~
$10.00 - Residential_
$25.00~ - Non-Residential
SOUTHOLD WASTEWATER DIS'POSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
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 OP. ALTERATION:'
OWNER OF PROPERTY: ~U~y~ C. ~t1~,'[~1'/1~' ~/~ ~
OWNER MAILING ADDRESS: ~ ~Y/~, ,~
TELEPHONE NUMBER OF CONTACT PERSON: ~-~
TAX MAP NO.: Section /~. ~ .Block ~, ~ Lot
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY :~
DATE: ~'[(~ / Town' Clerk's Office
Signature of Applicant
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