HomeMy WebLinkAboutPisciotta, Mario rOF`FtCE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk Application No.
Town Hall, 53095 Main Road Construction
P. 0. Box 1179
Alteration
Southold, New York 11971
Residential
Telephone �—
(516) 765-1801 Non-Residential
RECEIVED
TOWN OF SOUTHOLD
G
It_, 1986
Town CUrk Southold SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE
APPLICANT NAME: AR I o f �SCInT 1/q
APPLICANT ADDRESS: P1 WE�REE f20
COTch*(.0 ' 4)
SEPTIC CESSPOOLC__
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
- GoaAT'r 3o P"r 003 T
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY:- MAR a PI S c ( mq
OWNER MAILING ADDRESS: 60 6. Podb W ST
M_ A SSRPQ d& w/d' I/1,f'�
OWNER PROPERTY ADDRESS: Iolorli2EE 024AI)
G V !tom
TELEPHONE NUMBER OF Cc� -NTACT PERSON: 3 D2
MAP117`� /
TAX MAP NO. : Section Block Lot W L 3 J
CROSS STREET: �/ TTrRS&'jELT t.Ar ai
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Appli ant
RECEIVED BY: � -
Town CI rk's Offl ce
DATE:
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