HomeMy WebLinkAboutCon Anthony OFFICIg OF 'I'1~ TOWN CLI~I~
TOWN OF SOtPI'~OLD
F,L~ABKITI A. NEVILLE, TOWN CLERK
Telephone
(63-1) 765-1800
~WN OF SOUTHOLD
~TER DISPOSAL DISTRI
Application No3 1
Construction
Alteration
$10.00 -Residential /
$21.00 - Non-Reside,,,
ION or ~LTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME:
APPLICANT ADDRESS:
SEPTIC CESSPOO~
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: /~//~-~ ~ C~/~
OWNER MAILING ADDRESS: ~Z~ O~Z~/~ ~
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: 7;~--~Y~
TAX MAP NO.: Section 70 Block ~-~ Lot ~ ~
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY~~ ' ~
~ To~'n Ci~rk's Office
Signature of Applicant
DATE: