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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: '~/~
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