HomeMy WebLinkAboutOlsson, Frederick
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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 (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTH OLD
SOUTHOLD W ASTEW ATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Application No. j cP 7 h
Permit No.
Applicant Name 'F"f\ ~ "b e R \ C 11\ () 2- 5:7 0 N
Applicant Mailing Address -3 c;: L-EN'-Vo'tll A- c/ e.
If-A-S""(1NG--..5>-'1:>I\j- fktP>OJ-t - ~.':J. /D70 b
Septic Tank_or Cesspool ~
Brief Description of Proposed Construction or Alteration ~ E f'l. ACE Oc---p cpo ~L.-
lA? \'"tH- f{\;\P -rY'f:. C Q:.D .pOOL. C()~f>~S>
Residential@ $10_ or Non-Residential @$25_
Location of Proposed Construction/Alteration:
Owner of Property: -p RF"DI? 11..\ c. K Vt-. S><70/'(
Owner Mailing Address: '3 <0 j.. f; fJ wOOlS} h V t:. ,
rrA7l/t-Ifr5,.- ~H-- /hlp7@ftl N:::/. /b/06
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Owner Property Address: ~ 2. 8-11 AlA- .>..?'A<< jIJ fA fir- ec,.., '{.
eu-r-d oq~" --1'1---1' 110/<7>
Name and phone number of contact person) I\<..IC\-\-A~b Afh:.- (3., u. 0?9J'. 9'- r-Y
Tax Map No: Section / / / Block '-/- Lot .3 o. A
Cross Street if /4' r\! <7 '0 { ~
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
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Signature of Applicant Date
Received by: ~.A~
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TOWN OF SOUTHOLD BU LDING\DEPT.
765.1802 I :
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[r] FOUN . I"SUtAT I
[ ] FRAMI~G I STRAPPING (! If} r! ] RNAL_ ! .~
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[ ] FIREPLACE & CHIM~RE SAFEtY INSPECTION
[ ] FIRE RESISTANT CONSTRUC'nON [ ] F~E RESIST~ PENETRAnON
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REMARKS:~ /.~~7vC<'~.-t.
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DATE
1-- 11- 07
INSPECTOR ~,~