HomeMy WebLinkAboutSmith, Walter ET,TT,&BETH A. NEV~T,LE
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
Residential ~ $10
Applicant Name
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
7
. . or Non-Residential ~ $25 __ Application No.
Permit No.
PECONIC CESSPOOL
Applicant MailingAddress P.o. BOX 487
LAUREL, NEW YORK 11948
Septic Tank. or Cesspool_~¥__
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property:
Owner Mailing Address:
Owner Property Address: ISSO-
Nme ~d phone number of contact person
S .on
Cross S~eet
NOTE: LOCATION MAP MUST BE SUBMJ~TTED WITH A~xPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH ~IEALTH DEPARTMENT APPROVAL
Si~i~e o'fApplicant Date
Received by: (..,~ ~
%9-0
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
FOUNDATION 1ST
FOUNDATION 2ND
FRAMING / STRAPPING
FIREPLACE & CHIMNEY
FIRE RESISTANT CONSTRUCTION
[ ] ROUGH PLBG.
[ ]INSULATION
[ ] FINAL
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
REMARKS:
INSPECTOR ~---'
DATE