HomeMy WebLinkAboutPolywoda John Ol~lag OF TIi~ TOWl~ Cl,lm.E
TOWN OF
:rzAB~Ttt A. ~ TOWN CI.EIIK
P.O. BOX 1179
SOI. tlItOI~D, ~ yORK 11971
TelePhone
(632) 765-1800
Application
Construction ,,
Alteration
$10.00 - Residential
$25,00 - Non-Residentia~l
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
APPLICANT NAME:
APPLICANT ADDRESS: ~---~. o, ~-y" / ~"'~ '~
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: ~---O ~ ~ -+ --'~---~ ~'~CP~Cy ~aJ~313"'
OWNER MAILING ADDRESS: ~ ~ ~,~ ~
OWNER PROPERTY ADDRESS: ~ ~?~ ~/~
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section 7~ Block
CROSS STREET:
Lot /-7
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY:~~~
DATE:
Clerk's Office
SURVEY OF LOT 42
MAP OF I~EST GIP. EEK ESTATES
FIL~ ~UST I% 1~6~ FILE No.
TO~, ~~L~
~GT~ IOO0-~-I-I~
SU~VE~E~ 12-0~-01
NA~ A~ENDED~
T~L Hole
5/22/,02
NOTES:
· P'iONUi'dENT FOUNEP
O PIPE FOUN[~
AREA = 23,-/OI 5F OR 0.64 AG. RE5
SEPTIC. SHOP, IN FOR THIS LOT IS PROPOSED
NO PHYSlOAL EVIDENCE OF AN OLD HOUSE
OR SEPTIC- S'FSTE~ ON THIS LOT
®P. APHIC, DC, ALE I"=DO'
N
SIJFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
P~RMIT FOR APPROVAL OF CONS~U~ION ~R A
LOT
4-1
JOHN C. EHLERS LAND SURVEYOR
6 EAST MAIN STREET N.Y.S. LIC. NO. 50202
R1VERHEAD, N.Y. 11901 REF.\'d-Ip server~d~PROS\01-303.pro
369-8288 Fax 369-8287