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PERA�ITDATE COMPLIAIVCI `DATE:
Separation Distance Betw�n Ebe
Maximum A tYusted Grounduvaier Table to the.Bottom of LeAching Faci{�ty Feet
Pnvate hater SuppiyMe8l and Lac►ttng Fac�Itty ( any walls exist
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Edge of Watlattd and`:Leaclung Facility(If any wetlands exist ✓-
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LOCATION � CS�C SEWAGE #
-- VILLAGE \L ASSESSOR'S MAP & LOtI ' �S
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER t ��
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY d Ul7
LEACHING FACILITY: (type) CO (G P+r (size) 0 ov
NO. OF BEDROOMS I
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leachii facility) Feet
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