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LOCATION SEWAGE # a N - z S'O'
VILLAGE (�l`tt��1^�l� ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME & PHONE NO. `�• ��tiC t� 56t,
SEPTIC TANK CAPACITY ! 6 i�> c11 Lv
LEACHING FACILITYAtype) 214 (size) �66 6
NO. OF BEDROOMS 'Z PRIVATE WELL O PUBLIC WATER
BUILDER O OWN
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ' a-
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VARIANCE GRANTED: Yes Z-�No
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