HomeMy WebLinkAboutKrom AnnApplication No.'-~-~ ~/
q'elephone $10.00 -Residential ~
(63~) 765-1800 .J~.~ ~ $25.00 -Non-Residential_
~-~ .-,~/l/~/~~OWN OF SOUTHOLD
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
DATE~
APPLICANT NAME: PECONIC CESSPOOL
APPLICANT ADDRESS; P.o. BOX 972
MATTITUCK, NEW YORK 11952'
SEPTIC , CESSPOOL /
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP:
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTERATION:
OWNER MAILING ADDRESS;
Must be attached hereto before permit may be issued.
OWNER PROPERTY ADDRESS:
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: Section J~ .Block ~/~
CROSS STREET: ~z~..~-~.~
BUILDING PERMIT NUMBER CROSS REFERENCE:
Lot I ;;;Z, 0
Signature oK-'Applicant
RECEIVED BY:
· /> Towr~ ~'-~ffice '
DATE· ,. ,//~/f~/~ ~ .
Ann Krom
1280 Peconic Bay Boulevard