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tl� yr Town Hall, 53095 Main Road
04.4, ���� P.O. Box 1179
��0. Southold, New York 11971
JUDITH T.TERRYFAX(
T'#I' 765-1823
TELEPHONE)16)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. 1557-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WADELTON, PETER B.
Mailing Address 1 P. O. BOX 1174
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1370 WICKHAM AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4386
Tax Map No. section 139.00 block 3 lot 47.000
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK %c3�FFO(,(�-�-
Town of Southold �� _ �'��'� Application No. /5Z5-7
Judith Tzr. erry, Town Clerk .; ` .i 31
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s Residential
Towr��tlall, 53095 Main Road 8 � -'--:;',4..i:it� . $10.00
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P. O. Box 1179 to r r;..,._•,>r�* tri ; $25.00 - Non-Residential
Southold, New York 11971 O% r.. ',f '1 .$
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Telephone j NOV
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- - - - - - for — - - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ htoo
DATE /c// Oj9b
. 'OWNER NAME: 'Te"\.e.,/ ,VIA-Se.,:1)-v-> -
OWNER MAILING ADDRESS: R''® , $Di. 1Y� 'M
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OWNER--PROPERTY- A'1DRESS B 70 ( ) \
( t Tu ch._ , -;1' ) 19S 2--
OWNER TELEPHONE NUMBER: 5/& r. ()AS-Y. UIT ZS414°
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank V 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.)
V" 116 .
g,(AALA? "
• Signature of Applicant
RECEIVED BY:
• -Town Clerk's Office
• DATE:
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