HomeMy WebLinkAboutMercier, Thomas '~.T ,~,A.BErr.~. A. NEVI'LL'~.
TOWN CLERK
REGISTRAR OF V~TAL STATISTICS
MARRIAGE OFFICER
I~ECORDS MANAGEMENT
FREEDOM OF ~OP2.~T~ON OFFICER
Town Hall, 53093 Ms/n Road
P.O. Box 1179
Sou~hold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southold~own.nor thfork.net
OFFICE OF T~J~ TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
R~sidential ~ $10_~//or Non-R~idential ~ $25
Permit No,.
Applicaut Name
PECONIC CESSPOOL
Applicant Mailing.Address P.o. BOX ..487
LAURE!,; NEW YORK 11948
Septic T~r£~ .__or Cesspool
Brief Desc,'~ot/on, ~fPro~osed C. og~st;u, otion or Altera~?
Location ofPropose, d Construction/Alteration:
Owner Propm'ty Address: O0 ~
Name and phone number o f contact person - ~'~ c~
C~os.~S~e~ e~ ~ ~;gk _~--
Si gnat urkof~p'piicant Da~¢
Received by: