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Town Hall, 53095 Main Road
P.O. Box 1179
r_��® Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1410-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SUMPTER, WILLIAM AND VIOLA
Mailing Address 1 240 WICKS ROAD
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 240 WICKS ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5021
Tax Map No. section 110.00 block 8 lot 19.000
Cross Street NEW SUFFOLK LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/12/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK 'c��FFD(,(-�
Town of Southold � ., e%' Application No. / //o
Judith T. Terry, Town Clerk % itiw
y,A 1 $10.00 - Residential
Town Hall, 53095 Main Road =,;ham -
P. O. Box 1179 v3 'k }% i �a
� $25.00 - Non-Residential
Southold, New York 11971 Oi6:1
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Telephone :
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPL.ICAT ro, WtE2VI' D for
a-
M AR 0 7 1990 OPERATION PERMIT
Southold Town Cloth SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE fPh,,irc.11 6 /9', O
OWNER NAME: pin ash9 q Sum ti '
OWNER MAILING ADDRESS: 0 die d,
w ,.S'ie-p6 /I, my, /' /7J
OIANFR PROPERTY
OWNER TELEPHONE NUMBER: 74/ /
TAX MAP NO. : Section //6 Block 0 Lot tel
CROSS STREET: A - \5N_ i _
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: De:fpb.e/' /re'
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.)
*116:4,APt/ I
Signature of A.,, licant
RECEIVED BY: i
Town' Clerk' Office
RECEIVED
DATE: t,
Town Clerk Southold'
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