HomeMy WebLinkAbout24939-Z FORN NO. I
TOWN OF SOUTilOIoD
BUILDING DEPARTHEBT
TOWN IIALL
SOUTIIOLD, N.Y. 1197 I
TKI.: 765- 1802
INSTRUCTIONS
BOARD OF HKALTH ............. '..
3 SET8 OF PLANS ...............
SURVEY ........................
CHECK .........................
SEPTIC FORH ...................
NOT1FY:
eau. .... '7.6..~.~..~. 2.o..~
HAIl, TO; ....................
'Date ................ .19 ....
a. 'Ibis applicatioo n~mt be cono]etely filled in by L~/pe~riter or in i~ mi ~itt~ to O~ ~dlding I~ctor wi
struts or areas, ~ Bivi~ a ~tail~ ~ri~t~ o[ la. st of pm~rty ~t ~dr~ ~ tim di~mn d~id$ is ~rt of
(~tu~e o[ a~ltmt, or s co~rati~O
If a~ticant is a co.ratio, si~e of ~ly ~O~)ri~l offi~r.
(Nare and title of corporate officer)
Pl~mbera Liceme Eo ..........................
Electricia~ l.ice~me No ......................
I. location of land on ddd~ p~ ~ will ~~ ~..~.. .................. -..~ .......................
....................... ............... ....................... .
I~ ~r ' St~ i~et
~ T~ ~p ~. I~ ~ . ............. .. . I~ ...........
2. State existi~ m ~ ~ o[ ~i~ ~ inte~ m ~ ~ of pm~ ~t~t{~
~. ~ ,, ~ ~.~m~c.t~, ~~ ................................ : .........
II.
12.
13.
16.
15.
PI.OT DIAGRAH ~
It)cate clearly and dletinel:ly all LnaJldlnge, Mmrl~r exinl:ing or propoaed, and Indicate al! ael:-I~aek dln~naiona
properly lir~a. Giro atreat taxi block mm~er or dezcrlptio~ aecordh)g £o deed. and td~o~ atreeC r~ren and i~ligaue
~d~etber interior or corner lot.
,~'I'A'IE (]F II')t/ YOliI(,
OUI~Iy (Xt .......................
.......................................................... I)ei:,8 duly m~>rn, delx)se,~ and maya thor he J~ the appl. i(~JnL
(~nt~ of i~xlivichmL nignil~ e~traet}
I~ ia the . ., ~.4 .... ~.~...~ .~ .....
of ~d ~r or ~, m~ ]~ ~ty ~tl~t]~ to I~r~on. or lu~e I~rfor.~ the ~id ~k m~! to ~ke ond ~ile thi~
that tl~ wrk
' (SilFml:~,re ()~ A~)I leant) ........
~- ~, 8~k ~u~
N 4t'49'00" W 100.00'
N/O/F
LETITIA ~IALONE & ROBERT G. ~[ALONE