HomeMy WebLinkAboutAcvi, Kate & Gabriel
4CGG Town Hell, 53095 Main Road
ELIZABETH A. NZV rLLE y~ P.O. Boz 1179
TOWN CLEM Southold, Flew York 11971
1MGMMAR OF VITAL STATIMICS Q Fez (631) 765-6145
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MARRSAQE OFT'ICER Telephone (631) 765-1800
REMPOS WK&GMONT OFFICER southoldtowa.northfork•net
FREEDOM OF nMM"TION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF sourKOLD
SOUTHOLD WASTEWATERDISTRICT
APPLICATION p3 /jr~/r~
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK p /
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Residential @ $10_ or Noa Residential @ $1S _ Pee li~tNo.cationNo.
Name PECONIC CESSPOOL
Applicant
Appli=t Mailing Address P. O. Box . 487
LAUREL„ NEW YORK 11948
Septic Tom:- _or Cesspool
Brief De= ption of Proposed Construction or Alteration
Aron: a I C
Location of Proposed Co MCI
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owner of Property l ~t
Owner Mailing Address:
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Owner Property Address, l R
L~IeX Sia,-~~ ~Z
Name and phone number of contact G
Tax Map No: Section 3 Block Lot OI l
Cross Street
.
NOTE: LOCATION MAP MUST SE SUBMITTED. WITH APLI ON NEW
DEP R VAL
CONSTRUCTION REQUIRES SURVEY
Signature o Applicant Dat
Received by:
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