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HomeMy WebLinkAboutTotter Nahas ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS iMJkNAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION Town Hail, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1600 southoldtown.northfork.net CONSTRUCTION or AI.~TERATION PERMIT CESSPOOL or SEPTIC TANK Residential ~ $10 or Non-Residential ~ $25 __ Application No. ~2 B ~ Permit No. Applicant Name /0~ ,~ Applicant Mailing Address Septic Tank or Cesspool Brief Description of Proposed Construction or Alteration Location of Proposed Construction/Alteration: OwnerofProperty: .~o$.,a /~'off~z. o ~'/5l D~oR~cl'.I~s Owner Mailing Address: 57'. V-r/.~ .~ 3, AJ,Y' OwnerPropertyAddress.'ffOQl~/TT~~ k. Iq, 3- ~-~o~ac lq OoCO 0 z. tq ~ou T~ eL. ~ Name and phone number of contact person ~ oc ( AJ,*,'(,~ 5 / Tax Map No: Section 7o Block / 2- Cross Street ('~ tT.~,~ ~. ~' ~' ~",4 ~- ~--~',,.,.'~ Lot ? -) / NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL Sigm~re of Applicant - Date Received by: U ©