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HomeMy WebLinkAboutChomicki, Steven Q�q,Sur'�ft,0 `ElXZABLTHA.NE.'Vl'= a C' Town Hail,53095 Maim Road TOWN CLERK _ P.O.Boz 1179 REGISTRAR OF VITAL STATISTICS Southold,New York 11971 MARMAGE OFFICER Fax(631)765-6145 RECORM MANAGEMENT yr r jLLzr. ©� � Telephone(631)765.1800 FREEDOM OF INFORMATION OFFICER Sautholdtown.northfork.net OMCE OF IL TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION CONSTRUCTION or ALTERATION PERMIT CESSPOOL or SEPTIC TANK Residential @$10 or Non Residential @$25 Application No. Permit No. Applicaat Name PECONIC CESSPOOL Applicant Mailing Address P. 0. BOX _487 LAPREL, NEW YORK 11948 Septic Ts!- or Cesspool_ BriefDesc, ptio1af 01=r onstruction or teration Location of Proposed Constreiction/Alteratioa: (" f C1 OwnerofProperiy: �. 52 , �� Owner Mailing Address: .4AAU- .-. Owner Property Address: 315F IrtlAo. L954V 111k4%*&E /V tv Name and phone number of contact person Tax My No: S 'an 1 q 1 Block Cross StreetN*5IAP � pp�,�5 --- NOTE: LOCATION* MUST 8E SUBMHTEDzNVM APP CA ON. NEW CONSTRUCTION REQUIRES SURVEY HE R DEPAR RO AL Signa licallt /bate/ Received by- Y' Oct (06 C,L4 e--3 0-