HomeMy WebLinkAboutRozakis, Tom ELIZABETH A. NEVILLE =`Z` y� Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
y = Southold, New York 11971
REGISTRAR.OF VITAL STATISTICS
MARRIAGE OFFICER � • `F Fax (631) 765-6145
A
RECORDS MANAGEMENT OFFICER �f Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER O'` �a southoldtown.northfork.net
II
�� I3 OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
Q, SOUTHOLD WASTEWATER DISTRICT
��JJ APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 /or Non-Residential @ $25 Application No.
Permit No.
Applicant Name_///a2R� Sfs�
Applicant Mailing Address 0
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration 1k,1-7A/l aW, C 44ii/K
Location of Proposed Construction/Alteration:
Owner of Property:_ - a �OZ�/C•f
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person
Tax Map No: Section Block
,,��ff Loth
Cross Street �C.ep-Y1 �S
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEPARTMENT APPROVAL
r
Signature of Applicant Date
Received by:
{
1
WO 4
�«fob
u
1
M
C`7
Z-/� -------
i /
t -
f
1
1