HomeMy WebLinkAboutStulsky, Mark OFFI~R OF ~ TOWN CLggK
TOWN OF 8OLrl~OLD
J~AI~TH A. N~] ~: TOWN CLERK
P.O. BOX il?~
SOUTHOLD, NI~W YORK 11971
Telephone
(631) 765-1800
Construction
Alteration
$10,00 - Resideiatial
$25.00 '7 Non-~esidential
TOWN OF SOUTHO.LD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No, ;
APPLICANT NAME:
APPLICANT ADDRESS:
SEPTIC X CESSPOOL
DATE .I~_._G~_ ,4,, 2004
RICI~ARD SA~i-£A GEI~E1La_L COI~IT, ACTOR
P.B. BOX 2047
GR~-~'ORT~, ~ YORK 11944 ·
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
~ s¥~
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS:
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTERATION':'
OWNER OF PROPERTY: ~ARe: S~.~~ I
1005 .qOUTH gARROR ROAn
soIr/~oLD, ~ YORK 11971
TELEPHONE NUMBER OF CONTACT PERSON:
TAX MAP NO.: section 75 Block 04
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
RECEIVED BY: ~'~LL/-% ,,
j j Town Clerk's Office
DATE:
Lot 06
~gna~ure of AplSlicant