HomeMy WebLinkAboutToman Robert OF~(~ OY T~ TOWN (3~3~
'['OWN e~ SO~OLD
EL~ABE~I A.. NEV/LL~ TOWN CL~RK
BO. BOX 11 ?g
$OUTHOLD, N~W ¥OP.K 1 ~1
Construction
Alteration
Telephone . $10.00 - Residehtial
(635) 765-1B00 $25.00 - Non-Residential
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
DATE
APPLICANT NAME: ~_~l~t~('~ JO~
APPLICANT Al)DRESS: '~O ~) ~(42~C~_~
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:: - ' ' /..~3e-~-c~q L
OWNER MAILING ADDRESS:"JrBO ~z~ k~
TAX MAP NO.: S~etio. 7~ Block Dg Lot ' ~
/
~UILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY:
~ ~ Town Clerk's Office
Signature bf Applicant