HomeMy WebLinkAboutDeSimone Scott ELIZABETH A. NEVII,I,F,
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT 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 @ $10 /or Non-Residential ~ $25 __
Application No.'~ "2~q
Permit No.
Owner Mailing Address:
Owner Property Address:
Name andyhone number of contact person .~CtrzT"
Tax Map No: Section /~_/o Block / Lot 7
Cross Street ~-.,-t '~'~.~,,.,, ,6~e~_ {~_ i _~? ~-~ ~'~j~. /~_
NOTE: LOCATI& MAp MUST BE SUBMITTED/~ITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
S~o~ 6at~r
Received by: ~ ~
Applicant Name ~, t,-r'r%
Applicant Mailing Address
Septic T~ ~ or Cesspool
Brief Description of Proposed Cons~ction or Alteration
~cation of Proposed Constmctio~Alteration:
O~er of Property: ~
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