HomeMy WebLinkAboutSwiskey William Ol~IC~ OF '1'i~ 'I'OWN CI,ERK
TOV~ OF SOL~[IOLD
Ifl..IZABETH A. NEVILLE, TOWN
P.O. BOX
SOLrI~OLI), ~W yOP~K 1197
TelePhone
(632) 765-1800
TOWN OF SOUTHOLD
Application No.
Construction
Alteration
$10.00 - Residential
$25.00 - Non-Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee '$
APPLICANT NAME:
APPLICANT ADDRESS:
DATE
SEPT I C_~CESSPO O L
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: (.x.),)),O,,~ '~ ~c~V~ Sc~,s~:e~ ~c
OWNER MAILING ADDRESS: ~ ~
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON: q77
TAX MAP NO.: SectionO~, C~O Block
CROSS STREET: ('~oln
BUILDING PERMIT NUMBER CROSS REFERENCE:
Lot
RECEIVED BY: ~ ~z~_~_~
· Towff~Clerk~s Office
DATE: /c~/~2_ ,7/~ ~
~/~J-'~ ~ o(~Applicant
Signatul~