HomeMy WebLinkAboutMclane Mcguire3'OWN OF SOIJT~[OLD
~ ~ ~TH A. I~VILI~ TOWN C[.F-t~
p.O. BOX [ 179
SO[ri'HOLD, ~ YOR~ I 1~71
TelePhone
(63'~) 765-1800
Construction
Alteration
$10.00 - Residential
$25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No,
Fee $
APPLICANT NAME:
APPLICANT ADDRESS:
SEPTIC ,X CESSPOOL .....
DESCRIPTION OP 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: /~ ~Ly/~ ~ ~_ ~.
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: , M~ ~5--~-
TAX MAP NO.: Section ~' Block
c.oss STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY: T~Office
DATE: //c~F~,~,~_~[. i I
ignature o Applicant