HomeMy WebLinkAboutSamolewski RobertOFF[CE OF ~ TOWN CLIGIK
TOWN OF SOOTI~OLD
~T rZABL~ A. NI~Vw ] a: TO~ CLEKK
P.O. BOX i 1'/9
soUTHOLD, NEW YORK 11971
TelePhone
(63I) 765-1800
· Application No.
Construction ,
Alteration
$10.00 - Residential
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
Permit No.
Pee ' /0.oo
SEPTIC TANK or CESSPOOL
DATE
APPLICANT ADDRESS: 7FOO~//~-~J''&,
CESSPO0~ ~ J
DESCRIPTION OF PROPOSED CONSTRUCTION .OR ALTERATION
,/
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:'
OWNER MAILING ADDRESS;
TAX MAP NO.: Section /0
CROSS STREET: ~f~&~,~ ~,
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY:
DATE:
Signature of Applicant
JAN 2 1 2OO3
'/
Southold Town Clerk
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