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1 Town Hall, 53095 Main Road
��`� P.O. Box 1179
41 Southold, New York 11971
JUDITH T.TERRY .-, FAX(516)765-1823
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TOWN CLERIC
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 104-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner KOKKINOS, GEORGE
Mailing Address 1 TSOKANOS, STEVEN
Mailing Address 2 P. O. BOX 229
City St Zip PECONIC NY 11958-0000
Property Address 1 J'S FLORAL FANTASY
Property Address 2 MAIN ROAD
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-5125
Tax Map No. section 75.00 block 1 lot 16.000
Cross Street PECONIC LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/04/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
Town of Southold oS�FFo�re Application No.-
Jud kh T. Terry, Town Clerk �4; ' ,,, _.
', Town Hall, 53095 Main Road 8 -` °�t :4. I $10.00 - Residential
P. 0. Box 1179 cn xy4 *
$25.00 - ► • -Residers ial
Southold, New York 11971
Telephone - Q( ic
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No./de/id-1
Fee $ /0 (at
DATE
OWNER NAME: GQG\
e \KM(C-TOOS -I S-M )EN • `Ts 0 )1a6i0bs
OWNER MAILING ADDRESS: p(O OX
fc_o\\) oe .0-u\\ ‘1 ).-y
OWNER PROPERTY ADDRESS: \`tom f(Q )JD '
\ \9\-Cci
OWNER TELEPHONE NUMBER: g,
(3',`) -16 J
TAX MAP NO. : Section Block , �'1'' ` ��-` Lot \\\:-
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CROSS STREET: f r-cz-
TYPE OF SYSTEM: Septic- Tank - New Existing
Cesspool New Existing
Residential �--- Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED. BY: ,
Town- Clerk's Office
DATE:
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