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TOWN OF BARNSTABLE
LOCATION ��� ( c�1 t— SEWAGE#
VILLAGE ��IV�P.fi3 ��� iP_ ASSESSOR'S MAP&PARCEL 99 3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY L X i 5 F gv
LEACHING FACILITY: (type) (size) <�
NO.OF BEDROOMS
OWNER � la�i ,ca
PERMIT DATE: J COMPLIANCE DATE:
Separation Distance Between the: /V ,�,r�
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility CAI" f4t e. 09- meet
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
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