HomeMy WebLinkAboutJarrell Mark OFFICE OF ~IE TOWN CLEI/K
TOWN OF SOUTHOLD
ELLZABETH A. NEVILLE, TOWN CLERK
P.O. BOX 1179
SOUTHOLD, NEW YOI~K 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
Application No.
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 $
DATE
APPLICANT NAME: ~'~'/zZg~-L ~ 4,~ C~/%~iS,~~/0
APPLICANT ADDRESS: ,, ~ .. '
SEPTIC ~ CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION Of PROPOSED CONSTRUCTION,~OR ALTE.R,/kTION:
OWNER OF PROPERTY //~/~ ~b~ Il
TELEPHONE NUMBER OF CONTACT PERSON: (~7a)?r3-
TXX ~P ~o.: s~,o~ /~ ~,o~k ~ Lo~ /
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY:
OATE:
Signature of Applicant
T6wn Cler~i~C's Office JJECEIVED
APR 18 2003
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