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1/4k,'"*4"` �'' Town Hall, 53095 Main Road
C4VII, ® /`' P.O. Box 1179
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JUDITH T.TERRY _ -w,,,,oi1‘ FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 954-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BALACICH, ITALO
Mailing Address 1 6145 JERNICK LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 645 JERNICK LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-23614
Tax Map No. section 70.00 block 3 lot 14.000
Cross Street WELLS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 12/13/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
II III I
OFFICE OF THE TOWN CLERK COMA'�'- _
Town of SoutholdAlication No.
pp
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ` :C I Residential
P. O. Box 1179 cf3 Pi ;' Non-Residential
Southold, New York 11971
Telephone =
765-1801 -- - - - O! ��
(516)
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE CCQrn bLir 0� t c g g
•
OWNER NAME: BGL_QC1 C111
OWNER MAILING ADDRESS: (0I--4S `I yr CIC LCZf'1�
nu no4 K),\/ If�1ii
OWNER PROPERTY ADDRESS : (01-I5 ' VY\ tC . Lance
6OL -I-ho4d, 0\I I 1 q 11
OWNER TELEPHONE NUMBER: 1L65- a3 (p 14
y TAX MAP NO. : Section —10 Block 3 Lot I `i-
CROSS STREET: Wens Il-J2no
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Z—LAA,ci ICI SS'
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: 9,
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own Clerk's Office
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DATE: L ())
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