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ELIZABETH A.NEVILLE �f �d:
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LIZABETH A.NEVILLE /141-- .0°
�;� t Town Hall, 53095 Main Road
p9Ir�RK is i P.O. Box 1179
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OFFICE OF THE TOWN CLERK ',•°�J S " FOLke
TOWN OF SOUTHOLD
••'�� 'QG Application No.. ..0(1
ELIZABETH A.NEVILLE,TOWN CLERK
P.O.BOX 1179 on
Constructi
SOUTHOLD,NEW YORK 11971
�,. Alteration
Telephone $10.00 - Residential
(631) 765-1800
11/ $`?
� $25.00 -Non-Residential
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION •
for
CONSTRUCTION or ALTERATION PERMIT
• SEPTIC TANK or CESSPOOL
Permit No.
Fee .$ e
DATE �/` ( 6
APPLICANT NAME: / 4 4. 40
APPLICANT ADDRESS: 27,.1) . /e
SEPTIC CESSPOOL
DESCRIPTION OF -ROPOSED CONSTRUCTION OR ALTERATION
/
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION ORALTERATION:
. OWNER OF PROPERTY: 0-P-14,12; c�/2 - irj
'OWNER TILING ,AQQI ESS; ,C33ii? %e./il ,€ Q
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OWNER PROPERTY ADDRESS;
TELEPHONE NUMBER OF CONTACT PERSON: Pec 2Jd)
TAX MAP NO. : Section G / Block V Lot 222 •
CROSS STREET:
BUILDING PERMIT NUMBER CROSS REFERENCE:
Signature of Applicant
RECEIVED BY: W-J2A^-'
o n Clerk's Office
DATE: I��d�
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