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TOWN OF BARNSTABLE
LOCATION 7/, Za,,c 4 Zayr SEWAGE#.,200 X
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /,O,�7 6W ex-,1 tin
LEACHING FACILITY:(type) �_(size)
NO.OF BEDROOMS J
OWNER �,•✓
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S f" 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). feet
FURNISHED BY Z4W
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