HomeMy WebLinkAboutKokkinos, George ELIZABETH A.NEVILLE Town Hall, 53095 Main Road
TOWN CLERK p 'f P.O. Box 1179
COD Z Southold, New York 11971
REGISTRAR,OF VITAL STATISTICS I Fax(631) 765-6145
MARRIAGE OFFICER �if� O�� Telephone (631) 765-1800
RECORDS MANAGEMENT OFFICER ��l �a
F EDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10V or Non-Residential @ $25 Application No.
Permit No.
Applicant Name ' .
il fl 7/
Applicant Mailing Address z�� Ge
Septic Tank or Cesspool
Brief Description of Proposed Construction or Alteration /D
Location of Proposed Construction/Alteration: G
Owner of Property: n AaIx
Owner Mailing Address: -(o 0 6"c 2 2
Owner Property Address: /f 10— It s"
Name and phone number of contact person �76-_ -V
Tax Map No: Section tl,,b Block Lot .�
Cross Street Cc f}-d
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY,WITH HEALTH DEPARTMENT APPROVAL
^t' r
Signature ofApplicant Date
Received by:
d el-
20 6
io D�
* * * RECEIPT * * *
Date: 12/09/14 Receipt#: 179362
Quantity Transactions Reference Subtotal
1 Septic Permit-Construct- Resid. 4285 $10.00
Total Paid: $10.00
Notes:
Payment Type Amount Paid By
CASH $10.00 Morris, Cesspool
Name: Morris, Cesspool
2760 Yennecott Drive
Southold, NY 11971
Clerk ID: SABRINA Internal ID:4285