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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® ,!%
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .< Southold, New York 11971
MARRIAGE OFFICER V® si Fax (516) 765-1823
��e �, Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1898-R Residential X Non-Residential
Fee $- 10.00 Septic Cesspool X
New Existing X
Name Of Owner WICKS, FLORENCE A.
Mailing Address 1 P. O. BOX 314
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 31055 NORTH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-5058
Tax Map No. section 74.00 block 1 lot 36.000
Cross Street HENRY'S LANE
Date Of Last Pump Out 0/00/00
Issue Date: 5/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.rte` ,0
i *ICE OF THE TOWN CLERK cOFDUr
Town of Southold Application No. ,f--- er
Judith T. Terry, Town Clerk t $10.00 - Residential
Town Hall, 53095 Main Road a
P. O. Box 1179 ,z ,
$25.00= Non-Residential
Southold, New York 11971 O ®, `
Telephone *a. ^4,1 411. )‘�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE O �
OWNER NAME: E .b�� (��� f� u.) Ics
OWNER MAILING ADDRESS: 76.
OWNER PROPERTY ADDRESS: Nto
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OWNER TELEPHONE NUMBER: b/, ^ 7v 5-6
TAX MAP NO. : Section , (fig" Block J Lot
CROSS STREET: o r j3L4-A,Irt1S
TYPE OF SYSTEM: Septic Tank-- New Existing
Cesspool New Existing
Residential G/" 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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