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HomeMy WebLinkAboutDeSimone Scott (2) ELIZABETH A. NEVILLE TOWN CLERK REGISTKAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MA/~AGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hail, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 sour holdtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATERDISTRICT APPLICATION CONSTRUCTION o~ALTERATION PERMIT CESSPOOL or SEPTIC TANK Residential ~ $10 ~/or Non-Residential ~ $25 __ Application No. ,~q~ Permit No. 'Applicant Name ..~o'77'~ "~"- Applicant Mailing Address Septic T~ /or Cesspool Brief Description of Proposed Construction or Alteration Location of Proposed Constmctio~Alteration: Owner of Prope~y: ~o~ Owner Mailing Ad.ess: Owner Property Address: Name and,phone number of contact person ~'~ Tax Map No: Section ~&, Block ! Lot 7 Cross Street ~-,.~/~ '-.~,~..ake~A~ ; NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL Received by.' ~,~~b~ '%, / / ~%