HomeMy WebLinkAboutDemitt, James ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR 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~
......... Telephone (631) 765-1800
eoutholdt own.northfork.ne~;
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
Applicant Mailing Address
Application No. ~(
Permit No~
Septic Tanl~ ~ or Cesspool ~/'
Brief Description o f Proposed Construction or AIteration_j~x.,~/_~ff_~,,' c:~¢
Location of Proposed Construction/Alteration:
Owner of Property: '~ ~-~,~-_.q
Owner Mailing Address: ~-~)._ /L,'~¢; gl ,..,
Owner Property Address: IC)O~
Name and phone number of contact person ~,'~,~ L~f~//~-
TaxMapNo: ~OOO Section ]..3 Block
Cross Street .~)L~nO~ ?',i~,~'
Lot ,~, o~ 7
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Received by...~~ ~[~. ~t~re of A~pplicafli /O t~Date
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