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TOWN OF/BARNSTABLE
LOCATION SEWAGE#,�X4 01q
VILLAGE 44,gtS9unS /pf:-113 ASSESSOR'S MAP&PARCEL 57
INSTALLERS NAME&PHONE NO. I e. Ay lIT�' Z",
SEPTIC TANK CAPACITY l f�tJS
LEACHING FACILITY: (type) '"fV4044{/'S (size) /a•K3X075-'y'2
4 NO. OF BEDROOMS 3
OWNER
PERMIT DATE: 7—d COMPLIANCE DATE:
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 i}
within 300 feet of leaching facility) v` Feet
FURNISHED BY
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