HomeMy WebLinkAboutBeaury, FrankCONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
_~~'~' ~ OFFICE OF THE TOWN CLERK
SOUTHOLD WASTEWATER DISTRICT
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
Residential ~ $10
Applicant Name
Applicant Mailing Address
__ or Non-Residential ~ $25 __
Application No. t~0~q
Permit No.
Septic Tank or Cesspool ~/
Brief Description of Proposed Construction or Alteration
Location of Proposed
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Received by: '~~
Name and phone number of contact person
Tax Map No: Section ,y/ Block / 7 Lot do. F
Cross Street 3/*7 /0rt~
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
Signature of Applicant Date
SURx/E¥ OF: PROPERTY
SITUATE.. ~T M~ION
TO~, ~! ~
~OL~ ~~, ~
SIJRVETED 04--11-2012
SUFFOLK C,C~JNT~ T~
I000 - ~l - 7/ - 8.1
N
c]~l',l~! ~! ! TO:
I~NCIS P. BBAURY
MAI~I~N A. BHAURY
PlD~TY NATIONAL
Nq~URANCE C~MPANY
NOTES:
· ivIONUHENT FOUND
AP-JEA = 2~2~ S.F. or 0.5554 Acr~
®RAPHIC, SCALE I"= DO'
JOHN C. D'
6 EAST MAIN STREET N.Y.S. LIC. NO. 50202
RIVERHEAD, N.Y. 11901 369-8288 Fax 369-8287
REF. C:\UsersUohnkDropbox\06~06~06-222.pro