HomeMy WebLinkAboutDaversa Raniero OFFICE OF '1~ TOW~ CLERK
TOWN OF ~OLrI~OLD
ELIZABE~!~I A. NEVILLE, TO~N CL~P,K
P.O. BOX 1179
SOUTHOLD, NEW yORK 11971
Telephone
/.~ 765-18t~
TOWN OF SOUTHOLD
Application No.~/.~ ~
Construction
Alteration
$10.00 - Residential
$25.00 - Non-Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$ /0,
APPLICANT NAME:
APPLICANT ADDRESS:
SEPT,C X ,c ?po ._
DATE
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: ~(~Y) /~Vt3 ~/U/'3 ~i C~}'~L
OWNER MAILING ADDRESS: c~/~ ~ ~,
OWNER PROPERTY ADDRESS: ~ ~T ~0
TAX MAP NO.: Section //] Block ~ Lot
RECEIVED BY:
DATE:
UT/own Clerk's Office
l l(o ( a '5 .
Signature of Applicant