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L' CATION �D� 6)'+n ekkei Le C-i r SEWAGE# o `
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VILLAGE ��� Ol h S ASSESSOR'S MAP& LOT Al /6dc!l
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY � 61rit�rf
LEACHING FACILITY: (type) P,'�+� {�} (size) (O x
NO.OF BEDROOMS
BUILDER OR OWNER yl y1 4e
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PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: . Y
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
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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 o leaching facility) r_ Feet
Furnished
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TOWN OF B STABLE
LOCATION ofifflorflamA M SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S AME&PHONE NO.
SEPTIC TANK CAPACITY 14
LEACHING FACILITY: (type) am,W (size)
NO. OF BEDROOMS f
BUILDER OR OWNER
1.0
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
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 faci ' Feet
Edge of Wetland and Leaching Facility( etlands exist
within 300 feet of leaching facility) II� Feet
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