HomeMy WebLinkAboutStemke, Paul O~SOFFO~,~~o
ELIZABETH A. NEVII.LE ~ Town Hall, 53095 Main Road
TOWN CLERH P.O. Box 1179
Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS V. ~'h
MARRIAGE OFFICER O .ll` Fax (631) 765-614b
RECORDS MANAGEMENT OFFICER y~ Telephone (631) 766-1800
FREEDOM OF INFORMATION OFFICER O! ~ ~a southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD ~°~C r~ I I j'
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SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK /
Residential @ $10 or Non-Residential @ $25 _ Application No. ? ~ l~'
Permit No.
PECONIC CESSPOOL
Applicant Name
Applicant Mailing Address IAA
1~
Gr~~r,~~DdL2
Septic Tank_or Cesspool
Brief Descrip ' posed C nstruction or Alteration
CCE'
Location of Proposed Constmction/Alteration:
Owner of Property: ~ fe~~Ce ~(xil~
Owner Mailing Address: s'
Owner Property Address:
/ R / 3
Name and phone number of contact pe on Lc~ -a 93"C
Tax Map No: Section IO 3 Block Lot
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLIC ION. NEW
CONSTRUCTION REQUH2ES SURVEY WITH TH TMEN PROVAL
gSignature of App Ic Date
Received by: I 1 I~- 3
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