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TOWN OF BAR.NSTABLE
LOCATION 7 0Wz,-?n -: SEWAGE # —
VILLAGE ASSESSOR'S MAP&LOT>`/i ?� 1-T�7
INSTALLER'S NAME&PHONE NO. f1/L�L-it 7 7 SEPTIC TANK TANK CAPACITY ,SQL
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LEACHING FACILITY: (type) /r5 (size)
NO.OF BEDROOMS
W=MrOR OWNER �i�i�r cv2iis Ze dG���t�®
PERMUDATE: COMPLIANCE DATE: -
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility lr� i� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge oUWetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) /' Feet
Furnished by ?"e /S` �L�
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