HomeMy WebLinkAboutSarkus PeterOFFICE OF THE TO~ cLERK
TOWN OF SOUTHOLD
~LIZABETH A. NEVILLE. TOWN CLERK
P.O. BOX 1179
SOUTHOLD, NI~W yORK 11971
Telephone
(516) 765-1801
TOWN Of SOUTHOLD
Application No,.3
Construction V/
Alteration
$10.00 - Residential_
$25.00 -Non-Residentiall
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPL,CANT ADDRESS: ,,
SEPT 1 C__CESSPO O L~,_
DESCRIPTION OF~PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION Of PROPOSED CONSTRUCTIO~N OR ALTERATION:
OWNER OFPROPERTY: .. £~_ ~f¢¢¢_~.
OWNER MA,L,NO ADDRESS, ~ ~~
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER Of CONTACT PERSON:
/
TAX MAP NO o: Section "~(~¢:~ Block
CROSS STREET:
BUILDING PERMit NUMBER CROSS REFERENCE:
Lot 2/°'
Signature of Applicant
RECEIVED BY:
DATE:
Town Clerk's Office