HomeMy WebLinkAboutDraeger Eva OI*IFICE OF TItE TOWN CLER~
TOWN OF SOIYI~OLD
ELIZABETH A. NI]VILLE, TOWN CLERK
P.O. BOX 1179
SOUTHOLD, NI]W YORK 11971
Telephone
(5161765-1801
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.
Fee $
DATE
APPLICANT NAME: _,~.~4~.~
APPLICANT ADDRESS:
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
!/.~17
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION ,OR ALTERATION:
OWNER Or PROPER*V: ~_, _~_. ~.~.,~,~ ~
OWNER MAILING ADDRESS; hO. ~ ,~.C~'.~
TELEPHONE NUMBER OF CONTACT PERSON:~/;-~9
~AX ~x~ ~o.: s~:,io. /~ ~o:~ ~ ,o~
BUILDING PERMIT NUMBER CROSS REFERENCE:
S'ignature ~ App icant
RECEIVED BY: ,~own~
· , G~NTRAL
N. ?.T.£6'00'
DRIVE ,~'
100.00'
;5'
~XC~AYATION ;Nsp~C:T'O~ REQL)IRF:I~
FOR SANITARY SYSTEM
~Y HEALTH OE~ARTMENT
'AREA = ~2;O00 ~q. ff.
The Iocelio~s of wells end cesspools
~owe hereon ore from f~ld ob~er~dio~
and or from ~I~ chinned from o/hers.
LOT (~
io0.O0'
SURVEY OF
· LOT 125~
"CAPTAIN 1(~TD E~'TA TE$"
A T MA TTITUCK INLET
TO WN OF SOUTHOLD
SUFFOLK COUNTY. N Y.
1000- 106z 02-38
Scale; I" = 20'
Jan. 8,2003
ELEVA TION6 ARE REFERENCED
l ~ fo~ w/th lhe S TA.~ARDS FOR APPROV~
A~ C~ST~T~ OF SU~URFACE SEWAGE
~OSAL SYST~ FoR ~GLE FAMILY RE~NCE~
~d w~ a~e by the co~ns gel forth lhere~ ~d
'"" LoT (~
~C. NO. 49618
(63~ ~/~' (631) 765 - 1797