HomeMy WebLinkAboutCitti, Elizabeth EI.~ZABETH 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) 766-6145
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
Applicant Name
/ or
Non-Residential @ $25 __
PECONIC CESSPOOL
Application No. 3~S' 9
Permit No.
Applicant Mailing.Address P.o. BOX. _487
LAUREL, NEW YORK 11948
Septic Tank ~/ or Cesspool ,,~ '"
Brief Description of Proposed C61mlruction or Alteration
Location of Proposed Comtmction/Altcration:
Owner Prop~ty Address:
Name and phone number of contact person . ~-~F'- 5--/~
Tax Map No: Section / q/(/ Block / Lot
Cross Street
NOTE: LOCATION'MAP MUST BEU_.SUBMi~TTED WITH'APPI~CATION. NEW
CONSTRUCTION REQUIRES SURVEY V~I~I~/~EALTH DEPART~E~NT APPROVAI~
'
Signature of Applicant Date [
Received by: .
Iq7¢
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 PE#~ ~.ATION
REMARKS:
DATE
INSPECTOR