HomeMy WebLinkAboutKlos Frank 01~i(1~ OF ~ TOWN CIJ~RII
TOWN OF SOU'I~OLD
EI.IZABI~TH A. N~ ~ ~; TOWN
p.O,~X 11~
so%~o~. ~ YO~ 1197
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
Application No..~ /6 /
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
.~SEPTIC= ~ CESSPOOL ~
LOCATION MAP:
Must be attached hereto before permit may be issued,
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: OWNER OF PROPERTY; Fr~K ,---~s
OWNER MAILING ADDRESS: /~5"', J~t',~
. .. H~,~,.~. nH/~
OWNER PROPERTY ADDRE$8: ~ ~OO..
TELEPHONE NUMBER OF CONTACT PERSON;
TAX MAP NO.: Section ' ~l~ .Block~~Lot
CROSS STREET: ~ ~.
CROSS
RECEIVED BY ~_.,/~ ~ fl'
Town"~:lerk s O ~ce
Signature of Applicant
DATE: .........
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