HomeMy WebLinkAboutMurphy Edward ELIZABETH A. NEVILLE
TOWN CLERK
REGISTHAR 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 (6~} 7.65-6145. .
' 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
'/' or Non-Residential ~ $25 __
Residential ~ $10
Applicant Name
Applicant Mailing Address
Application No. 3~']~'
Permit No.
£o~[~.oiJ~~ Ng' Itq7!
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration: Owner of Properly: ~0_,.,,.~J-
Owner Mailing Address: ~So pla Ocd,~ t.~,~,-.-
Owner Property Address:
Name and phone number of contact person
Tax Map No: Section .~ '7 Block o 2_ Lot
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Received by.'~-'~¢
Signature of Applicant Date