HomeMy WebLinkAboutGwiazda, John ELIZABETH A-
TOWN CLERK
It~L.~flU~ OF VITAL STATISTICS
MAIIiUAGE oFFICER
REC.,OP, D8 MANAGEMENT
FRF, EDOM OF Ii,¢Fo~TION OFFICER
Town !-lnll; 53095 Main P. oacl
P.O. Box 1179
Sou~hol~, New York 119"/1
Fax (6~1) 765-6145
Telephone (631) 765-1800
southold~own.nor thfork.net
OFF~CE OF ~ TOWN CLERK
TOW~N OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
or Non-Residential (~ $25
Application No. q cO((9
Permit No. _
Applicant N~n¢
Applicant Msi!ing.Addmss
PECONIC CESSPOOL
P. o. Box ._487
LAUI~I~.I.; NEW ~ORK !,!948_
Septic Tzr~"...__~ Cesspool .. . .
~rlef DeSc, i~ion of Proposed Cggstmction ~ Alt~aon
Lo~o~ of~po,~ Co~=~o~mt~o~ , ~ -. j~ ~ .
Name and phone ~umb~r of ~ct p~on
T=~o: s~o~ 3q .~'o~ ~~ I. I
$i~a~~C~{ Date
R~cdved by. _ ':