HomeMy WebLinkAbout0215 HIGH STREET - Health Faks -
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LOCA..TION AAQA 5 SEWAGE #
VILLAGE h2CS ,�.Yirrt.�,bl�2 ASSESSOR'S MAP&c LOT
INSTALLER'S NAME&t PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY-,(• (size)
NO.OF BEDROOM
BUILDER OR OWNER 10av t d( pi"et {nit► r-4 k 'Gt m mPn,i
PERMITDATE: 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
within 300 feet of 1 aching facility _ Feet
Furnished by 0,dsr 3
�X k7 Pecr
PCs_.
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