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Home My WebLink AboutRoberts Custom Homes ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS · -~.ARRIAGE OFFIOER ...... RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (~1) ~6~-6145 - Telephone (631) 765-1800 · southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION CONSTRUCTION or ALTERATION PERMIT CESSPOOL or SEPTIC TANK Residential ~ $10 ~or Non-Residential ~ $25 __ Application No.._~ Permit No. Applicant Namo~) g> ~f7g b &~f &rYl Applicant Mailing Address ff'~ ~t' t~ ~4 ~,~ Septic Tank / or Cesspool Brief Description orProposed Conslruction or Alteration_ Location of Proposed Construction/Alteration: Owner of eroperty:'~ b~ r--/ Owner Mailing Address: ~ Owner Prope~y Address: Name and phone number of contact persoh~0 ~ Tax Map No: Section ~/ Block ~ Lot Cro s NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. ~EW CONSTRUCTION REQUI~S SURVEY WITH HEA~ DEPARTMENT APPROVAL Si~atur~ a~ AE~lica~t 5'/p l i/if ? z z Received by: