HomeMy WebLinkAboutMessina, Donna ELIZABETH A. NEVII,T,E
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 (631) 765-6145
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
Residential ~ $10 V/~or Non-Residential ~ $25 __
Application No. 3'~---%'~
Permit No.
ApplicantName~'~_a3/,.~tt~ ~,~_<~:.% t
Applicant Mailing Address~____~ ~ ~-~
Septic Tank){ or"C'esspool
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:"-~o
Owner Mailing Address:
Owner Property Address: /'~ft~:/,..)O/'(..- ~'it//--L. /.~
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Name and phone number of contact person
Tax Map No: Section
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
signature ~'fAl~P]i~an~ .... ' 51t/e '
Received l~y:
OF PROPERTY
SITUATE: MATTITuG~
LOT NUN11~Et~ 5HORN HE~EON
REFER TO HINoF~
NAP OF ......... 8DIVISIO
5URvEyEp 01_14_0¢
SUFFOLK C-OtJNT¥ TAX
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JOHN C. EHLERs LAND SURVEYOR
6 EAST MAIN STREET
RIVER,E.IEAj), N.Y, 11901 N,¥.$. LIC. NO. 50202
369-8288 Fax 369-8287
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