Loading...
HomeMy WebLinkAboutMejsak, Thomas _ _ _ _ _ ~~PfO~,Yc ELIZABETH A. NEVH.LE ~'L`~ °~y~ Tawas P O SBox 1M9 n Road TOWN CLERK ~ Z Southold, New York 11971 REGISTRAR OF VITAL STATISTICS W - nt MARRIAGE OFFICER O~ ~ l.1C Fax (631) 765-6145 RECORDS MANAGEMENT OFFICER ~ southohdtown northfo k net FREEDOM OF INFORMATION OFFICER ~1 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION t CONSTRUCTION or ALTERATION PERMTI' I / CESSPOOL or SEPTIC TANK L~ Residential @ $10 V or Non-Residential @ $25 _ Application No. l ~ Permit No. PECONIC CESSPOOL Applicant Name Applicant Mailing Address ~f~€~_41 adA Septic Tank or Cesspool Brief Description Const~yon or Alteration ®~t,~XiL CAS Location of Proposed Construction/Alteration: Owner of Property: T ~ wta~ l - I Om~Z ~ I~SSc..~ Owner Mailing Address: 5 ~ Owner Property Address: / ~ ~ ©w~- Name and phone number of contact person ~-{`3'~ - ~9j°Z Tax Map No: Section Block a- Lot Cross Street NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW CONSTRUCTION REQUIItES SURVEY WITH HEALT EPARTMEN PROVAL Signa t Date Received by: 1 ~L~ ~ ~ ,s V V i ~ sal ~ c~ b ~°S~ ~ ~i o ~~45T'J f N