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No.2-153LY
UPC 12934
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LOCATION 4Z� /9* C/lrl4 SEWAGE #
VILLAGE W r L 9 �(�ASSESS ASSESSOR'S MAP & LOT? -00Y
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INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY Z, B
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LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR UBLIC ATER
BUILDER OR OWNER L
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:.5_v. /li,,//a/
VARIANCE GRANTED: Yes No
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