HomeMy WebLinkAboutMott TOWN OF SOgllIOLV '
p,o. BOX 11~
SO0"tHOI~), ~ yOl~ ll~l
TelePhone
(63t) 765-1800
Application No.
ConstructiOn
Alteration
$10.00 - Residential
$25.00 - Non-Residential
TOWN OF SOUTNOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
APPLICANT
APPLICANT ADDRESS:
SEPTIC ~CESSPOOL
D__~IL~ON OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATJON:'
. OW.ER o~ PROPERTY: ~-~ ,~ ~ ~.~.~
OWNER MAILING ADDRESS:O~ ('~,~. ~c~
OWNER PROPERTY ADDRESS: g~ ~ 'TA~ ~
TAX MAP NO.: Section .,~ BIo~ ~ ~t 15+2g
CROSS STREET: ~1;~~ ~)~
BUILDING PERMIT NUMBER CROSS REFERENCE:
bignature of Ap~licant~
RECEIVED BY:'
w' ce
DATE: '-~/~ !/0.2