HomeMy WebLinkAboutNordstrom OFFICE OF ~ TOWN CLERK
TOWN OF SOU'YI:IOLD
I~ABETH A. NEVILLE, TOWN CLERK
?.O. BOX 1179
SOUTHOLD, NEW YORK 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
Application N o. '-~
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 ADORESS:~)O~e -7(9 ~.,
SEPTIC ~.,CESSPOOL~
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:,
OWNER OP PROPERTY: ~~ - ~Z.~ (~V~
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section OO ~ Block (~
CROSS STREET: ~ ~)~ ~,
I
,
Lot I?-~
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED
I ~- Town Clerk's Office
DATE:
Signature of Applicant
TITLE NO.
! iJ'l / ' : ~ Sanita~ System not to be insall~
~~ '1,~.~ ~~ u~er driveway.
i ~ .[ .~ ~ ~ ~ FOR ~PROVAL OF CONSTRU~ION FOR A
' / m' ~..~ b~GLE FA~LY ~S~ENCE O~Y
FOR [~
I PLEASE NOTE
Minimum d~st<.nc~ belween well
NOO'47'~O"W ~' ,,,a
BURTON
BEHRENDT
MAP OF DESCRIBED PROPERTY SMITH
ENGINEERS
SURVEYED: OCTOBER 28, 2002 REV.~EPLOT WELL12/lO/02 SURVEYORS
SCALE: 1" = 50.00' FILE NO: 02--406 FAX
I