HomeMy WebLinkAboutAlvarez Roger ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS IdANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971"
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown,northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION'/Ir A~TERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 or
Applicant Name
Applicant Mailing Address
Non-Residential ~ $25 __
Application No. ~-q
Permit No.
Septic Tank.v" or Cesspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:~..o~aC ~.~J A 0~"-~-~
Owner Mailing Address: ~ ~ ~ %"~
Owner Property Address: '-[2. O,~ ~-\k]
Name an~t phone number of contact person ~
Tax Map No: Section/o[ Block OI Lot
_7o4t,
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURJLF<Y WITH HEALTH DEPARTMENT APPROVAL
~~) (J~X Si~natur~o f Applicax~ Date
Received by: ,
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