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HomeMy WebLinkAboutTaggart Jason OFFICE OF l'~ TOWN CLERK TOWN OF SOUTItOLD ELIZABETH A. NEVILLE, TOWN CI~RK P.O. BOX 1179 soUTHOIJ), 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, Fee $ //~~ APPLICANT NAME: ~-~'~:~o~n k ~,~ o o,m ~ APPLICANT ADDRESS:/~C ~/X ~fl / t ' SEPTIC CESSPOOL DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION LOCATION MAP: Must be attached hereto before perm t may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION: OWNER MAILING ADDRESS: /© z/? )~")~,~4J' I ~ ~0' OWNER PROPERTY ADDRE~S~: ~J~ ~ ~ TELEPHONE NUMBER OF CONTACT PERSON: TAX MAP NO.: Section 71~'. Block CROSS STREET: ?//?t~.~ //~7"t2'/ ,. Lot 27 BUILDING PERMIT NUMBER CROSS REFERENCE: RECEIVED BY: DATE: wn /C/lerk's' Office ig t u~'o ~ Applicant E ~ _. ~ ~ I ~ ~ ~ ~ ~ : STREET ~ ~ tr~es