HomeMy WebLinkAboutCianfrogna Maria ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS M-kNAGEMENT 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 or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ Sift ./or Non-Residential ~ $25 __
Applicant Name //~/~O~ "*~(~dd ~'Tt~,,3~t~,'~a-
Applicant Mailing Address -'7 ~ ~'- //~'t/-~,~d~k-
Septic Tank ~or Cesspool
Application No. ~ c~0 ~
Permit No.
Brief Description of Proposed Cousiruction or Alterat!,o,n Re [.oCo,'~ b.~,,3
T~,'k. iO'~Yt4 tge~ f~c~ p~r SC~t4eopec'~. ' '
Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person
Tax Map No: Section
Cross Street ff~"/"
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
SignatUre-of Applicant Date
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