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HomeMy WebLinkAboutBayberry Builders OFFICE OF ~ TOWN CLERK TOWN OF SOUTItOLD ELIZABETH A. NEVILLE, TOWN CLERK PO. BOX 1179 sOUTHOLD, NEW YORK 11971 Telephone (516) 765-1801 TOWN OF SOUTHOLD Application No. Construction / Alteration $10.00 - Residential / $25.00 - Non-Residential SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for CONSTRUCTION or ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No, DATE ~' 3 APPLICANT NAME:1 APPLICANT ADDRESS: pO G~. . ~.[1 SEPTIC /C[SS~OOL ~ DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION LCc._ LOCATION MAP: Must be attached hereto before permit may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: OWNER OF PROPERTY: ~f:~6[ L~}'~ 7Ct~/ OWNER MAILING ADDRESS: ~O ,' OWNER "ROPERTY ADDRESS~ TELEPHONE NUMBER OF CONTACT PERSON: CROSS STRE[T: ~ BUILDING PERMIT NUMBER CROSS REFERENCE: ~//" ~ Si~na'ture of Applicant RECEIVED BY: Town Clerk's Office DATE: