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LOCATIONS SEWAGE #
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VILLAGE
ASSESSOR'S MAP& LOT-�
INSTALLER'S NAME&PHONE NO.
{ SEPTIC TANK CAPACITY 0"U?�
i ;LEACHING FACILITY: (type) c C (size) 73
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: S 0� COMPLIANCE DATE: �' 4
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 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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TOWi1V OF BARNSTABLE�
LOCATION 6� Gr�J op SEWAGE #
VILLAGES : ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. y
SEPTIC TANK CAPACITY Id�N , ej•�
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR @W-N5R j
DATE PERMIT ISSUED: 2 - �
DATE .-COMPLIANCE ISSUED.
VARIANCE GRANTED: Yes No
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