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VILLAGE Q,,,.L.Q,, ASSESSOR'S MAP&PARCEL o S-b 2 Y
INSTALLER'S NAME&PHONE NO. V V29
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SEPTIC TANK CAPACITY (S 3 0
LEACHING FACILITY.(type) Al) A-rK Yet lr (size) (CO. 3 O
NO.OF BEDROOMS °
OWNER
PERMIT DATE: — I Z— Z'o i p COMPLIANCE DATE: r7 — w Za l
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility d u. 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
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