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PERMIT DATE: iO-7- J COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
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site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
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LEACHING FACILITY: (type) �� .f (size)
NO.OF BEDROOMS
BUILDER OR OWNER �4�- ��� '� ff
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
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Edge of Wetland and Leaching Facility(If any wetlands exist
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NO.OF BEDROOMS
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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
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Edge of Wetland and Leaching Facility(If any wetlands exist
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NO. OF BEDROOMS }}
BUILDER OR OWNER S�A01n/ POne C&I
PERMIT DATE: 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 facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leac 'ng facility) Feet
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INSTALLERS NAME&PHONE NO.
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LEACHING FACILITY: (type)
NO.OF BEDROOMS l r�
OWNER .S`1/�J�nw P& C 0n G 0 f
PERMIT DATE: 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 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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