HomeMy WebLinkAboutStack, John REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OF~'~CER
FREEDOM OF ]lqFORMATION OFFICER
Town Hall, 53095 Msin Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.nor thfork.net
OFFICE OF TH ~: TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $t0 ~ or
Applicant Name
Non-Residential ~ $25
PECONIC CESSPOOL
Application No. 3 9 ~ ~"
Permit No.
Applicant Mailing.Address P.o. BOX ._487
LAUREL, NEW YORK 11948
Septic TarOt or Cesspool
Brief D esc))iplj~ o~ Proposed Construction_or Alte~tion
Location ofProposexl Constmction/Alte[afion: , __
Owner of Property:
Name and phone number o£ contact person
~om ~oc~Tio~ ~ ~sT s~. S~B~TT~WI~. ~~0~. ~W
s
C ~gnature of Applicant Date
Reeeivexl by:
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
] FOUNDATION 1ST
] FOUNDATION 2ND
] FRAMING / STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] F~R~mT~'r~
[ ] ROUGH PLBG.
[ ] INSULATION
[ ] FINAL
[ ] FIRE SAr,. i T' INSPECTION
[ ] FIRE RESISTANT PENETIMTI0fl
REMARKS:
DATE
iNSPECTOR ~,-~