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LOCATION ��0\+L1p�► SEWAGE # _
VILLAGE ��t�.S�Ns���l , ASSESSOR'S MAP & LOT OIS C
DiSTALLER'S NAME&PHONE NO. `
h SEPTIC TANK CAPACITY UX�Q93^L
LEACHING FACILITY: (type) l t"MeAZ� (size) y .
NO.OF BEDROOMS 32
BUILDER OR OWNER
PERMITDATE: I to -'I�__ COMPLIANCE DATE:
Separation Distance Between the: i
Maximum Adjusted Groundwater Table
3a Fc-c
Private Water Supply Well and Leaching Facility (if any wells exist
on site or within 200 feet of leaching facility) F� ;
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Fe ;
Furnished by 1—. A.L
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