HomeMy WebLinkAboutGlasser FrederickOFFIC~ OF TI~ 1'0!~I ~
'l'OW~ o~otrl~Ol.~
~A.~TO~
P.O. ~x 11~9
~o~, ~WYO~ 11971
TelePhone
(63~t) 765-1800
Application No.
Construction
Alteration ~//,/
$10.00 - Residential
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
APPLICANT NAME:
APPLICANT ADDRESS:
SEPTIC CESSPOOL
DATE
i/.??I
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto~e~gfor/~,per,mit may be is~sja~ed. /--~/. _ ,~_
OWNER MAILING ADDRESS:
-,~ o~ ~ ~//~
TELEPHONE NUMBER OF CONTACT PERSON:
BUILDING PERMIT NUMBER CROSS : ,
RECEIVED BY: '/~w~ Clerks Office
~: ,,/~//~/~ ~