HomeMy WebLinkAboutClausen GustaveApplication No.~,2~/~ ~._
Construction ~ ~
Alteration
Telephone ~ ~ · · $I0.00 -Residential ~
(63~t) 765-:1800~'~ ~/]. : $25.00-Non-Residential
. T,OLD WASTEWATER D,SPOSA' D,STR,CT '
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
APPLICANT NAME:
DATE
PECONIC CESSPOOL
APPLICANT ADDRESS: P.o. BOX 972
MATTITUCK, NEW YORK 11952'
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 OF PROPERTY: ~ ,~- ~/'~/,~ ~'~-~f.~
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Sectlon//~,~-~ Block
C-~S STREET: ~ ~7~,
Lot
BUILDING PERMIT NUMBER C/ROSS REFERENCE:
RECEIVED BY~~~
~ro~wn~erk's Office --
DATE:
Signature 6f Applicant
GustaYe Clausen
5595 Pequash Avenue
Cutchogue