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HomeMy WebLinkAboutChew Janice Telephone (63't) 765-1800 Application No.~/ Construction ~_ Alteration $10.00 - Residential ~ $25 o 00 - Non-Residential TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for CONSTRUCTION or ALTERATION PERMIT SEPTIC TANK or CESSPOOL Permit No. Fee '$ ff~ ~ DATE APPLICANT NAME: APPLICANT ADDRESS: / SEPT,C CESSPOOL,~, DESCR~.~,ON oF PRO.OSED CONSTRUCT,ON OR ALTERATION ~J~ /J~- ,, , LOCATION MAP: Must be attached hereto before permit may be issued. LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION':' OWNER OF PROPERTY: OWNER MAILING ADDRESS: OWNER PROPERTY ADDRESS: ~'"~/C~- U~F..,oJ TELEPHONE NUMBER OF CONTACT PERSON: TAX MAP NO.: Section /~ Block CROSS STREET: _~-~-2~7~- ~/,~ BUILDING PERMIT NUMBER CROSS REFERENCE: S~gna-ture of Apphcant RECEIVED BY: '~/~ J\