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HomeMy WebLinkAboutHegermiller Robert OFFI ,'~ OF TI~ '1'O 1~'~ TOWN O1~ SOU'IHOLD EL.iZABErtt A. ~ ToWN CLER~ P.O. BOX 1 !79 $OUTHOLD. ~ YOP,~ 11971 Telephone (63~) 765-1800 A p.c tio" Construction ~ Alteration , $10.00 - Residehtial ~ $25.00 -Non-Residential TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for CONSTRUCTION or ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No. Fee '$ APPLICANT NAME: APPLICANT ADDRESS: SEPTIC i~ 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 OF PROPERTY: ~.O~.¢_T- OWNER MAILING ADDRESS: 7~ OWNER PROPERTY ADDRESS: ~/o/~-~'r POI~:> I~J). TELEPHONE NUMBER OF CONTACT PERSON: ~1~- II~ TAX MAP NO.: Section, ~ Block ~ Lot ~ CROSS STREET: ~~ I ~ ~. BUILDING PERMIT NUMBER CROSS REFERENCE: Signature of Applicant. / ~/Town/Clerk's Office DATE: 3¥ 3 ,,. Inlet Pond Road N69°02' 10"E 130.00' ~ Lob ~ Lot ~ "Mop of E©steen Shores Lot # 127 - g~ ~, Lot ¢ 126 ®RAPHIG SCALE I"= JOHN C. EHLERS LAND SURVEYOR 6 EAST ~ 8TRIer N.Y.S. LIC. NO. 50202 ~, N.Y. 11901 369-8288 F~x 36g-8287 REF,-TIGER~PROS\99-300A