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TOWN OF ~OUTHOLD
~AB~TH A. NEVU. LE, ToV~ CLERK
?.O. BOX i 1 ~
SOUTHO~, ~W yOP. K 11971
T~ephone
(63~) 765-1800
Permit No.
Fee $
TOWN Of SOUTHOLD
Application No.
Construction
Alteration
$10.00 -Residential .
$25.00 - Non-Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCT ION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
DATE
,, '.'. APPLICANT NAME:
~ "~ESSPOOL
. SEPTIC
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
· . LOCATION MAP: Must be attached hereto before permit may be issued°
LOCATION OF PRO POSF-_O CONSTRUC~T~ION OR ,ALT~/~/kTION: OWNER OF PROPEI~TY:
OWNER MAILING ADDRESS:
OWNER PROPERTY ~DDRESS:
TELEPHONE NUMBF~. OF CONTACT
TAX MAP NO.: Se~:tion (~'~ Block ~,/
CROSS STREET: ,_.~___..4/_~;~,~ /~Z~-_ ~
BUILDING PERMI~ NUMBER CROSS REFERENCE:
RECEIVED BY. ·
Tow~ ¢21erk'~ 'Office
Signa~dre of Applicant
b.
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