HomeMy WebLinkAboutOneill Timothy ELIZABETH A. NEVILLE
TOWN CLERK
REGISTBAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFOPdVIATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nor thfork.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 '~/7~q"/~
Applicant Mailing Address
Septic Tank. or Cesspool ~
Brief Description of Proposed Construction or Alteration
Application No.~O~/~ '~
Permit No.
Location of Proposed Construction/Alteration:
Owner of Property: .~/1~ 0 7'~:
Owner Mailing Address: ~,5 '-_l.~tl4d~/G~]
Owner Property Address:
Name and phone number of contact person
Tax Map No: Section ! I ~ Block
Cross Street
//?g 3
Lot
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH ilEALTH DEPARTMENT APPROVAL
Signature of Applicant Date
Received l~y: 7 ~(0~n ~, _
Lo 'LZ.~