HomeMy WebLinkAboutWoloski DanOI~IC~ OF ~ TOWN
TOWN O~ BO~E~OLD
P.O. BOX i 179
SOUTHOLD. NBW YORK 11971
Telephone
Application No3/'~)
Construction , ~
Alteration
$10.00 - Residential ~
(631) 765-1800 $25.00 -Non-Residential
CONSTRUCTION °r ALTERATION PERMIT ~ SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME:
PECONIC CESSPOOL
APPLICANT ADDRESS: P.O. BOX 972
MATTITUCK, NEW YORK 11952'
SEPTIC, .CESSPOOLL''''
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: ss ki
OWNER MAILING -~-~F~. , ~
ADDRESS:
OWNER PROPERTY ADDRESS:__ ~._~,.~_~ ..
TELEPHONE NUMBER OF CONTACT PERSON:~L~-~~
TAX MAP NO.: Section / ~// IDIock / Lot Lr23 /
BUiLDiNG PERMIT NUMBER CROSS REFERENCE:
- 5ignatur~ of ~pPli-c'ant
RECEIVED BY:
DATE: ~/~ ~/~ow; Clerk' s Of Jice
Dan Woloski
280 Pine Street
Mattituck