HomeMy WebLinkAboutOdell BogerO1~1,~ O1~ 1'1~ TOWN CLRRIt
TOWN OF SOUTItOLD
~T .17ABI~TH A. NEt/H I F~ TOWN CLERK
P.O. BOX 1179
SOUTHOLD. NEW yORK 11971
TelePhone
(63't) 765-1800
TOWN OF SOUTHOLD
Application NO.~L~
ConstructiOnv~/,
Alteration
$10.00 - Residential ~'/
$25.00 - Non-Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEIVED
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
DEC 6 °°'~
Southold Town Clerk
Permit No.
Fee '$
APPLICANT NAME:
APPLICANT ADDRESS:
SEPTIC CESSPOOL
DATE '~ ~ ,,,,J~. (~
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP:
Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:'
lift-IH
OWNER OF PROPERTY: ~So~- ~}~/.. I~
OWNER MAILING ADDRESS: ~ 0~,~
OWNER PROPERTY ADDRESS: g~5 ~,~J
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section ~ Block 0~
CROSS STREET: ~ ~*~ L~
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED B
nAT E:
Signature of Applicant
./