HomeMy WebLinkAboutBaxter William OFL~C~ OF TI~ TOWN CI, lmK
TOWN OF 8OUTIIOLD
ELIZABEI'ft A. N~VILLE, TOW~ CLBP. K
P.O. BOX i179
$OUT/{OLD, NEW YORK 11971
Telephone
(63.f) 765-1800
Application N o. __~d~'~'
Construction
Alterafion
$10o00 - Residential
$25.00 - Non-Resi dential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
DATE
APPLICANT NAME:
APPLICANT ADDRESS: ~'~.~-.~5 ~/~ ~, .
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: /~.~ ~:~0~ ~.
TAX MAP NO.: Section ~2 Block
BUILDING PERMIT NUMBER CROSS REFERENCE:
r"-~ignature of Applicant
RECEIVED BY: ~ ~.,~-J0,~-~ .
Townt Clerk's OffiC~
DATE:..
SITE PLAN