HomeMy WebLinkAboutMatheson Cindy OF ~ TOWN ~
TOWN OF ~OWI'I~OLD
A. NEVILLE, TOWN EDERK
P.O. BOX i179
$0u'~G-leDo, NEW yORK 11971
Telephone
(63~} 765-1800
Application No. 3
Construction ~
Alteration
$10.00-Residential ~
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DIsPosAL DISTRICT
APPLICATION
fo r
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME:
DATE
APPLICANT ADDRESS:
SEPTIC Y CESSPOOL
DESCRIPTION OF PROPOSI~D CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: ~-,~'~:,-~ ~1'~,~-'~
OWNER MAILING ADDRESS: ~ ~---1~-~ ~, ~X'Y'~
OWNER PROPERTY ADDRESS: ~0~, '
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section ~' Block
CROSS STREET:
BUILDING PERMIT NUMBER GROSS REFERENCE:
RECEIVED BY:
Signature of Applicant
Office
DATE:
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