HomeMy WebLinkAboutHaynes MarkOFFICE OF TIlE TOWN ~
TOWN OF SOUTROI~
p~ .rZABETtt A. NEVILLE, TOWN CLERK
P,O. BOX i 179
SOUTI'IOLD, NEW YORK l 1971
TelePhone
(63'~) 765-1800
Application No. ~./~-d~
Construction /
Alteration ~
$10;00 - Residential
$25.00 - Non-Residential
TOWN OF 5OUTHOL0
SOUTHOLD WASTEWATER DIS:POSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
APPLICANT NAME:
APPLICANT ADDRESS:
SEPTIC X' CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP:
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION':' · OWNER OF PROPERTY: ~.4 .~t~ -~ ~
OWNER MAILING ADDRESS: '5~ ~c~z~,~o
OWNER PROPERTY ADDRESS: ~r~-3o TLIE ~ ~.~-~'
TELEPHONE NUMBER OF CONTACT PERSON;
TAX MAP NO.: Section ~o Block
CROSS STREET: ~ ~.o~J~
BUILDING PERMIT NUMBER CROSS REFERENCE:
· RECEIVED BY:
DATE:
Must be attached hereto before permit may be Issued.
Lot
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