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HomeMy WebLinkAboutShearin JanOFFICE OF 1[HE TOWN CLEI~ TOWN OF SOL"I~OLD ~ .r','AB~iH ,~ N'Hvrr I/:_ TOWN CLERK P.O. BOX 117¢ $OUTHOLD, N'~ ¥ORI( 11971 Construction Alteration ~ - $10.00 -Residential Telephone (63~) 765-1800 ~/- $25.00-Non-Residential ~ SEPTIC TANK or cEssPOOL ~outhol~Tow. O~,~ Permit No. Fee $ APPLICANT NAME: APPLICANT ADDRESS: SEPTIC CESSPOOL~x/ DESCRIPT~POSED CONSTRUCTION OR ALTERATION /. LOCATION MAP: Must be attached hereto before permit may be issued. '0~AT'ON O~ PROPOSED CONSTRiCT'ON O:~/'LTERfT,ON: OWNER OF PROPERTY: / /~ ~ _ OWNER MAILING ADDRESS: ~"~~~/( OWNER PROPERTY ADDRESS: TELEPHONE NUMBER OF CONTACT PERSON: ,X~'-' f5® TAX MAP NO.: Section /~ Block ~- Lot / ?* / CROSS STREET: ~//~-~':'~ BUILDING PERMIT NUMBER CROSS REFERENCE:  S~'gnature of Applicant RECEIVED BY: ~ . T~n ~rk's Office