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Application
Construction
Alteration
$10.00 - Resldent]aJ
$25.00 -N0n-Residential
TOWN OF SOUTHQLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
CONST'RUCTION or ALTEt~ATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Faa $
DATE
APPLICANT NAME:
APPLICANT ADDRESS:
DESCRIPTION OF f~ROPOSEb CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit' may be Issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION;'
· OYINER OF PROPERTY: ~ ~r"['l~4,k~ ~ ~LI C ~ ~'~/¢°
OWNER MAIlING ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: ?~.~-?~-'~(~
TAX MAP NO.: Sactlon (01~" Block t') / ~Lot ~
caoss ST~z: P~/~' U/~ ~' .. ,.
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED By'~~ ,
\ t Tov/n ~-erk s Office
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