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S M E A
KEEPING YOU ORGANIZED
No.10334
2.153L,
MWE IN USA
GET ORGANISED AT SMEAD.COM
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LOCATION ! • F"Fe, SEWAGE # 1 7a
VILLAGE /� ����C�V�. ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 1
SEPTIC TANK CAPACITY i to as--O
LEACHING FACILITY: (type) =, a, .a (size) Z�' y
NO.OF BEDROOMS
BUILDER OR OWNERv �� z A A
PERMITDATE: _/ 4 ' 7 COMPLIANCE DATE: fir 22
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 300 feet of leaching facility) Feet
Furnished by
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