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SEPTIC TANK or CESSPOOL
Peri. it No,
Fee '$
APPLICANT NAME:
DATE
PECONIC CESSPOOL
APPLICANT ADDRESS: Po O. BOX 972
HATTITUCK, NEW YORK 11952'
SEPTIC CESSPOOL t/
LOCATION MAP: Must ba aitached hereto before permi[ may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ,ALTERATION:
· OWNER OF PROPERTY= $~, ~ C~//
OWNER MAILING ADDR~S: ~ ~ ~ /
OI~NER PROPiRTY ADDRESS: ~
TELEPHONE NUMBER OF CONTACT PER$ON:j~d~gS~~'"~ "~
A : Sa-t~on / B)ock /J Lot/~V'~' ~/~V'~'
BU[LD~NG PERMIT NUMBER CROSS REFERENCE:
RECEIVED EY:
T~a C~e~kl~' OFfice
DATE;
BRUCE & MAUREEN CAMPBELL
620 MEDAY AYENUE
'MATTITUCK