HomeMy WebLinkAboutKrom, Laurie F.r JV~BETH A. NEVILLE
TOWN CLER2K
REGISTRAR OF VITAL STATISTICS
IVm/I.RIAGE OFFICER
RECORDS 1ViANAGEAiENT OFFICER
5RIEEDOM OF IbVFOP24ATION OFFICER
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
R~idential ~ $10 ~
OFFICE OF T~i~3 TOBrN CLE1R~
TOVglN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTPdCT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
or Non-Residential ~ $25 __
Application NO. ''% '~ ~ ~0
Permit No
Applicant Name
PECONIC CESSPOOL
Applicant Mailing Address
P. o. BOX 487
LAUREL, NEW YORK 11948
Septic Tz,J or Cesspool
Brief Desc:.ptio--~ of Proposed Construction or A, l(eration
\~.,.~ ,.,~( C~"~ ~,lo~'~.
Location of P~oposed Construction/Alteration:
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person
Tax Map No: Section / ~//
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED/~I, T~I APPLICATION. NEW
Signature of Ai~phcant Date
Received by: