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ELIZABETH A~ NEV~.T.F.
TOV~N CLERK
REGISTI~R OF WTAL STATmTICS
MARRL~GE OFFICER
RECORD~ NL~NAGENfENT OFFICER
FI~EEDOM OF ~FORNiATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, Mew York 11971
Fax (631) 765-6145
Telephone (631) 766-1800
southold~own.northfork.net
OFFICE OF T~ TOWN CLERK ' TO~/q OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
CoNsTRucTION or ALTERATION PERt~
CESSPOOL or SEPTIC TANK ~
Residential ~ $10 [///or Non-Residential @ $25 .
Application No.3 (~"]-"~
Permit No.
Applicant Name
PECONIC CESSPOOL
Applicant Mailing Address P. o. BOX .787
LAUREL, NEW YORK 11948. __
S~ptic Tank ~' or Cesspool .
Brief Des~ril~tj~c~..of Proposal Construc~or~?~ Alteration
Location of Proposed Constmcj~ordAltcrati_'on:
Owner of Property: ~ O,~_.KT ..~C
Owner Mailing Address: · .~3 C) , tL~tFI e
Owner Property Address:
Name and phone number of contact person
Block ~-- L°t ] ~-D~' ~
Cross Street
NOTE: LOCATION MAP MUST BE SUBMI.~TED WITH APPLICATION. NEW
Co sr ucno
§ignature-of Applicau '
Received by:
LOT 38
HICKORY AV£
SURVEY'iOF PROPERTY
A T $OUTHOLD
TOWN ~)F SOUTHOLD
SUFFOLK COUNTY, IV )~
~ DEC. 22, ~gg7
97 - 417