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TOWN OF BA TABLE ��n�"•
LOCATION i
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VILLAGE Ott=1�C�_ASSESSOR'S MAP&PARCEL
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INSTALLER'S NAME&PHONE NO. �
SEPTIC TANK CAPACITY CAr 13frtm6 pfI66
LEACHING FACILITY:(type) T7, a-L-S (size) i`7 lc�`7'•5' ��-
NO.OF BEDROOMS
OWNER '(t2_4-_L-
PERMIT DATE: -[ -i( COMPLIANCE DATE: �)
Separation Distance Between the: o
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..l w re, r
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