HomeMy WebLinkAboutOliver, Benjamin ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
$outhold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 ~// or Non-Residential ~ $25 __
Application No. ~[~t~
Owner Name C 14 ~ 6~l/t LC7
Owner Mailing Address
Permit No.
Owner Property Address
Owner Telephone No.
Tax Map No: /~ecti9n , 1~[{o . Block "] Lot ~(~)
Cross Street f ~'f-/'~
Please check each ~at applies: New Construction
Alteration to Existing System
Residential ~/'~ Non-Resid~
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate_~i~ance in feet fr~-~stem to,,,b~ding
and closest road. New construction may submit copy o~su~,ey with SC appro
Received by: / t,,'!/
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2ND
[ ] FRAMING / STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUCTION [
[ ] ELECTRICAL (ROUGH) [
REMARKS:
[ ] ROUGH PLBG.
[ ] INSULATION
[~FINAL
[ ] FIRE SAFETY INSPECTION
] FIRE RESISTANT PENETRATION
] ELECTRICAL (FINAL)
DATE //~ ' ~/-/~ INSPECTOR /~'f~' :' ~