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No. 42101/3 ORA
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TOWN OF BARNSTABLE uql
OCATION ®-U SEWAGE #
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VILLAGE �Vw
ASSESSOR'S MAP & LOT
QINSTALLER'S NAME PHONE NO.:
SEPTIC TANK CAPACITY �7
BLEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
4BUILDER OR OWNER V` S,!j
DATE PERMIT ISSUED:
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DATE COMPLIANCE ISSUED: /G T
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VARIANCE GRANTED: Yes No
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