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S MI E A
KEEPING YOU ORGANIZED
No. 10334
2-153L
MADE IN USA
GET ORGANIZED AT SMEAD.COM
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TOWN OF BPRNSTABLE M 05h (shy
LOCAWN Cry
VIi.LAGE � � ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNE �G 1�"C.._�a —j,d
PERMITDATE: COMPLIANCE DATE:
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) �„�o Feet,
Furnished by P
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