HomeMy WebLinkAboutNorth Fork Management ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS iVLANAOEMENT 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
southoldt own.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
Residential ~ $10 /or
CESSPOOL or SEPTIC TANK
Non-Residential ~ $25 __
Application No. ~c-Sk
Permit No.
Owner Name
Owner Mailing Address
Owner Property Address
Owner Telephone No.
Tax Map No: Section ~ Block 7 Lot //
Cross Street ~/~ ~//X/f'- ,~
Please check each that applies: New Construction J
Alteration to Ex~ System
Residential Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
Signature of ~pplicant /./ Date
Received by: ~
RS
LANE