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LOCATION DO(' C'' SEWAGE It Jam'
VILLAGE /V �?
) ASSS�ESSO/R'S MAP & LOT � 3O
INSTALLER'S NAME&PHONE NO. .3/7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 't (size)
NO.OF BEDROOMS
BUILDER.OR 0 1 1,
PERMITDATE: �COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Watet%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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