HomeMy WebLinkAboutRosin Steve ELIZABETH A. NEVILLE
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 _ _
Applicant Name
Applicant Mailing Address
Application No. 3~155
Permit No.
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:.
Owner Mailing Address:
Owner Prope~y Address:
//9 ~z/o
Name and phone number of contact person
Tax Map No: Section /Y/
Cross Street
Block / Lot Z-cZ ff
NOTE: LOCATION MAP MUST BE SUBM1TT/ED WITH APPLICATION. NEW
CONSTRUCTION REQUIRE .S SURVEY WIT~IE/OQLTH DEPARTMENT APPROVAL
Signature-o 'Apl;licant ' /~)ate/
Received 'by:j~}'{ ~,L ~k~k- i.
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