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LOCATION
SEWAGE # 1
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INSTALLER'S NAME&.PHONE NO.
SEPTIC TANK CAPACITY pJ ®®6•
LEACHING FACILITY: (type) /l�F✓P�C;7�(/ (size)
NO. OF BEDROOMS �Z
BUILDER OR OWNER
PERMITDATE: CON PLIANCE 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 Wedand and1eaching Facility(If any wetlands exist `
within 300 feet of leaching facility) Feet t
Furnished by 4
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