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VILLAGE ANN!S ASSESSOR'S MAP & LOT J"M`-2 06
INSTALLER'S NAME&PHONE NO'. A4 AC d,44 1-fPf I— .Sam
SEPTIC TANK CAPACITY G• �� G®�
LEACHING FACILITY: (type)
NO. OF BEDROOMS
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BUILDER.OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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