HomeMy WebLinkAboutMcCourt Kathryn ELIZABETH A. NEVILLE
MARRIAGE OF~FICER
RECORDS MANAGemeNT OFFICER
{ ~ APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765~1800
southoldtown.northfork.net
Residential ~ $10
Applicant Name ~0
Applicant Mailing Address
Non-Residential ~ $25 __ Application No. 2~"~/
Permit No.
Septic Tank or Cesspool ~
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person J/f-
Tax Map No: Section / ~f ~' Block
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURLY ~W~H HEALTH DEPARTMENT APPROVAL
Received by: ~X~. Signature of Applicant Date