HomeMy WebLinkAboutBarry, James & Kathryn +A$ETS A.NEVE LLE
TOWN CLERg
?-EMMAR OF VITAL STA ZMCSTown 53095 Mam Road
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MACE OMCM v- P.O.Bos 1179
RECOM)sM `°�G T O CER Ay �'� So F O14 New York 11971
DOM OF DZF0MdAT16N OFFICER (631) 766-6145
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WN TOWN OF SOUTXOLD SRR D � 1.
SOU'FHOLI}WASTEWATER DISTRICT
APPLICATION
CONSTRUC-MON or A L
TERATION
CESSPOOL or SurnC �LST
Residential @$10 1/
or Non-Residential Qa $25
Application No.J'z r(o
Applicant Name Petit No.
PECONIC CESS o.
Applicant�gAddress' P. o fox 487
Sept-
Septic Tom;; I-ATIREL, NEWypRK 11948
BriefD
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L �On 4r Alteration
Location of PMPOSed C0=446
on:
Owner ofProperiy;
OwwnerMailingAd
Owner Property,Address: j
Name and phone number of contact person
Tax Map No:
section 136 Block f
Cross street O zAt
NOTE: LOCATION- AMST BE s
CONSTRUCTION REQUIRES SURVEY D APP
DEPAR TION NEW
ROVAL
Sigaature o ,Applicant
Received by: Date
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