HomeMy WebLinkAboutSenenfelder Tom ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORM_4TION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (631) 765-1600
southoldtown.north£ork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION,or ALTERATION PERMIT
CESSPOOL or 'SEPTIC TANK
Residential ~ $10 or
Applicant Name ' RO 6'~' 7/'
Applicant Mailing Address .,~ ~- 6 ~ ~
Non-Residential ~ $25 __
Application No .'~,.~_
Permit No.
Septic Tank or Cesspool__
BriefDescr/pti0n or'Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:. ~ ~
Owner Mailing Address: ' >[6'x
Owner Property Address: .~ ,?~- ~',~ ~' ~ ~',0 ~'~ /~
Nalne and phone number of contact person
Tax Map No: Section ~[O Block ~ Lot
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED W..[TH APPLICATION. NEW
CONSTRUCTION REQUIRES. SURVEY '-'~JJJ~JJW I T H/I~;q~D E P ~;VI~Ii,N T APPROVA~
~r~n~t~ r~ o f At~dfi~'~t Date
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