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Application No. ~ I~
Construction ,//
Alteration
$10.00 -Residential
(516) 765-180.1 $2B.00 -Non-Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
fOF
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Fee $
APPLICANT NAME:
APPLICANT ADDRESS:'-~, .C~ I]'~C.~.,L ~'~O~
S~PT~ C__~CEssPooL j
D~SCRIPT~ON O~ P~O~OS~D COnSTrUCTION O~ ^LTE~ATiON
LOCATION MAP: Must be attached hereto b~(ore permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: C I i ~-e--k-k3£'lrle~ A
OWNER MA~.INC ADDreSS: I ZR . Le~
. C~e~ ~t~,,
OWNER PROPERTY ADDRESS:. ~_~ ~
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section ~/ Block / O
CROSS STREET: ,/~OC,ZI~ . '~(-~7 P--
BUiLOING PERMIT NUMBER CROSS REFERENCE:
RECEIVED
DATE;
3/- ?.k' e'-/o.~2
Lot ~ · O0 /
S~E3nalu're of Applicant
Office