HomeMy WebLinkAboutPeters John T O~1¢1 CE OF T~ TOWN CLERK
TOWN OF SOUrHOLD
ELIZABETH A. NEVILLE, TOWN CLERK
p,O. BOX H79
SOUTHOLD, NEW YORK 11971
Telephone
(63~) 765-1800
TOWN OF SOUTHOLD
Application No. '~
Construction J
Alteration
$10.00 -Residential ~'~
$25.~0 - Non-Residential.
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE
APPLICANT NAME: ~'-O~ -'~.
APPLICANT ADDRESS: ~"~.(~,
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: -'aRH
OWNER MAILING ADDRESS: ~'~-0' {~ ~
OWNER PROPERTY ADDRESS: [~5 ~~ ~
TELEPHONE NUMBER OF CONTACT PERSON: ~'~'~5
TAX MAP NO.: SectionO~.O0 BlockO~-~ Lot ~,
CROSS STREET: ~l~ ~
BUILDING PERMIT NUMBER CROSS REFERENCE:
Sig~attYre of Applicant
RECEIVED BY: .~L~....
Town
Clerk's
Office
DATE:
III