HomeMy WebLinkAboutBroderick JudyOFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
Application
Construction
Alteration
Telephone $ I 0.00 - Residential
(516} 765-1B01 $25.00-Non-~:f~
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Fee $
DATE
APPUCANT NAME: S'Cl
APPLICANT ADDRESS: ~-~ ~_~-u~-
SEPTIC CESSPOOL X~
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY:
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OWNER MAILING ADDRESS:__
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OWNER PROPERTY ADDRESS: ~ ~' ~.~
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section '? ~" Block '~
CROSS STREET: [~l~'~'~.~',~ . ~)~.,~'-~
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY."~~M']
k'' Sigr~a{ure'of-~pplicant