HomeMy WebLinkAboutHermance RonaldOFl~CE OF 't'~k TOWN CLERI(
TOWN OF SOUTHOLD
~[/TABEI~ A. NEVILLE, TOWN CL~RK
P.O. BOX i179
$ou'rHOLD, NrBw YORK 1197l
Telephone
(63-?) 7(;5-1800
Application NO.~/~
Construction.,
Alteration
$I0,00 - Residential
$25,00 - Non-Residential
TOWN OF SOUTHOLD
~ ~,. J CONSTRUCTION or ALTERATION PERMIT
~~ SEPTIC TANK or CESSPOOL
Permi{ No.
Fee $
DATE
APPLICANT NAME: d~'/~Y6~'~-~L~ ~ ~ .~O~/~. ~(~-~7~
APPUCANT ADD,ESS:
SEPTIC ~CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
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:
OF
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY:
/T~/Wn Cler//'s Office
DATE;
240 BRIAR LANE
SOUTHOLD, NEW YORK
, /
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICE~
PERMIT ~O~ ~9~O'VAL OF CON~I'RUC'I'iON I~R A
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. ~s ~;,~ ~A~S faoM DA ~ o~ A~*~OVAL
] ~~ INSPECTION REQUlaE~q
[ '~ITARY SYSTEM
~ L ~H DEPARTMENT ,, _~
'!
'SUBJECT TO TOWN APPROVAL OF
GRADING AND DRAINAGE PLAN.
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