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TOWN OF BARNST.ABLE
L.00A.TION 3? 4'2-0ZX 1111 1 4 SEWAGE #
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VkLAGE Pya �� ,� < `I�c�- ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
M SEPTIC TANK CAPACITY 5A c\
LEACHING FACILITY: (type)'M't 3 1 Aet-+, r c (size)
NO.OF BEDROOMS
BUILDER O OWNE
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 exisi
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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