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LOCATION ��>.� c� SEWAGE #
VILLAGE ZZI 4 �i?> -s ASSESSOR'S MAP & LOT Q vv`'�
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) tw-< (size)
NO: OF BEDROOMS .PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER kojy �A>
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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