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~
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