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7-7 C �
TOWN OF BARNSTABLE y^�
LOCATION 2 SEWAGE# `40� 3 /�
VILLAGE — V� \� ASSESSOR'S MAP&PARCEL Za T U 7
INSTALLER'S NAME&PHONE NO. m1� ��
SEPTIC TANK CAPACITY 1��® c,
LEACHING FACILITY: (type) 4 b(size) 1(�
NO.OF BEDROOMS
OWNER
PERMIT DATE: 1,01A — 37y COMPLIANCE DATE: 2
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
I 300 feet of leaching facility) Feet
FURNISHED BY
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