HomeMy WebLinkAboutWisniewski, Joseph Y A.r LTILLE Town Hall,53095 Main Road
Tp Gy�g P.O.Boa 1179
Southold,New York 11971
REGISTRAR OF VITAL MTIMCS Fax(631)765-6145
MAMA OFFICXR
O� Telephone(631)765-1804
RECOBDB MANAGEDQBIZT OFFICES
FREEDOM OF INFORMATION OFFICER sautholdtGwz-northfork.net
OMCE of TEE TOVN CLERK
TOWN OF SOUTHOLD
SOUTSOLD WASTEWATER DISTRICT
APP .�hN
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 or Non Residential @$25 Application No.l �v
Permit No.
ApplicantName PECONIC CESSPOOL
Applicant Mailing Address P. O. BOX .487
LAUREL, NEW YORK 11948
Septic T=- or Cesspool
Brief DeSca'-.3daft osed C on or 'on
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Location of Proposed Alteralipn: r ('
Owner Of 4 GS 12 l ESS
own pea'�y-
Owner Mailing Ad
Owner Property Address: Cx"85 Rt&aL.�
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Name and phone number of contact person
Tax Map No: Section /Y-3 Block 41 Lot
Gass Street
NOTE: LOCATION•MAP MUST BE SUBMITTED APPLI ON. NEW
CONSTRUCTION REQUIRES SURVEY ARTMENA . OV
7 /
Signature of Wlicait Date
Received by:
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