HomeMy WebLinkAboutTravers, James SISFFQZ/r
ELIZABETH A. NEVILLE �`t` �Gy Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
C4 Z Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS 0 Fax(631) 765-6145
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MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER y1f�1 �aO� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
v'U TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $101— or Non-Residential @ $25 Application No. .�
Permit No.
Applicant Name &agj�
Applicant Mailing Address A7 y�/y�lf G° rr
Septic Tank or Cesspool *-,/
Brief Description of Proposed Construction or Alteration A_�A'__cy
Location of Proposed Construction/Alteration:
Owner of Property: Aa xr
Owner Mailing Address: 5�� Jed 9 0,e ,►
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Owner Property Address:
Name and phone number of contact person
Tax Map No: Section (:/zAS Block _ Lot
Cross Street 0 0raAzt='eL-61
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SUR WITH HEALTH DEPARTMENT APPROVAL
Signature of Applicant Date
Received by:
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