HomeMy WebLinkAboutMoglia JohnSOUTItOLD, N~W YOP, X 11971
TelePhone
(63'~t) 765-1800
Application No. ~/_~.
Construction ,h~
Alteration
$10.00 - Residential~
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DIS'POSAL DISTRICT
APPLI CAT I0 FI
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
APPLICANT NAME:
APPLICANT ADDRESS:
J o
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:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section ~.~2 Block
CROSS STREET: ~0 .~?W
BUILDING PERMIT NUMBER CROSS REFERENCE:
//'~Sig natu r~/b-f Applicant
RECEIVED BY:'(~ ~L'~~-~
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