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ELIZABETH A.NEVILLE �o.t° ®�y„A'4, Town Hall, 53095 Main Road
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TOWN CLERK ® ` P.O. Box 1179
t t Southold,New York 11971
REGISTRAR OF VITAL STATISTICS riPs41? '�� Fax(516) 765-1823
MARRIAGE OFFICER �1
RECORDS MANAGEMENT OFFICER - 0 �® 1� Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER `` �' ���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3782-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner WICKHAM, PETER P.
Mailing Address 1 3854 TRAILRIDGE ROAD S.E.
Mailing Address 2
City St Zip CEDAR RAPIDS IA 52403-0000
Property Address 1 179 OLD HARBOR ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 319-363-3884
Tax Map No. section 117.00 block 3 lot 1 .000
Cross Street
Issue Date: 4/10/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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OFFICt OF THE TOWN CLERK V FU(,U( -7
TOWN OF SOUTHOLD �� CDy Application No. /
ELIZABETH A.NEVILLE,TOWN CLERK � ;5.+ .;�,. �� $10.00 - Residential
P.O.BOX 1179 f.11 , ,,
SOUTHOLD,NEWYORK 11971 •®s $25.00 - Non-Residential
Telephone -40 4 �� ,'
(516) 765-1801
TOWN QF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /� (9 0
. DATE A-prid
OWNER NAME: Pe4er P. Vl/a`c_kflc co
OWNER MAILING ADDRESS: 3 s14- Irdt lric{je RA _ S -E-
Ce t- Rr p 4 c 5 -%A 524.0 33
OWNER PROPERTY ADDRESS: Ng Old Hag-4-'0r Rd__ _ -
New u f i i‹. ) I_.._._1 N.Y.
OWNER TELEPHONE NUMBER: C 31 ci) - 3453— gg Sg
TAX MAP NO. : Section 4113 3 g Block 117, Lot 3 --
CROSS STREET:
TYPE OF SYSTEM: Septic Tank- = - New Existing
Cesspool t,00‘r' New Existing
Residential t/-7 Non-Residential
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.)
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Signature of Applicant
'R'ECEIVED 'B:Y:_ . -
Town Clerk's Office '
DATE: •
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