HomeMy WebLinkAboutNorell, Robert E ET,TZABETH A. NEVI~J,E
TOWN CLERK
REGISTI~i~ OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS NLa. NAGEMENT OFFICER
FREEDOM OF ~rFOPJV~TION OFFICER
OFFICE OF THE TOIArN CLERK
TOV~N OF SOUTHOLD
SOUTltOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10_~ or Non-Resident/al ~ $25 __
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.north fork.net
Application No. ~ 7~
Permit No
Applicant Name
PECONIC CESSPOOL
Applicant Mailing Address P. O. BOX. ~87
LAUREL, NEW YORK 11948.
Septic .TcC or Cesspool
BriefD~so~l'ation of Pml~osed Construction or $1teration ~- ~ ~
Location of Proposed Constmction/Alter. ation:._ · ~ ~
Owner of Property: ¢0¢~? ~-%'° ~ (~ ~ ~-'~ {~
Owner Mailing Address: ~ q c~ ,~,, 5~ .5 ~ .~---~ ~. ^
Name ana phone number ofconta¢iperson ~_~ 5q-Cf ~9~1<~ -- l(~
Tax Map No: Section 1,.~(o Blocl< {~ Lot ~
Loc,norqmJs ,i. PLICAnO?5 tw
CONSTRUCTION REQUIRES SURVEY(~~ ~D~~JT/_~)PROYAL
/~ Signatur'-e~:r~pp licX~nt Date
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