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TOWN OF BARNSTABLE
LOCATION L�L SEWAGE#
VE LLAGE ASSESSOR'S MAP& LOT 3O
INSTALLER'S NAME&PHONE NO.
'u SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) .�SSlf��� (size)
NO.OF BEDROOMS
$ ^OR OWNER J 6 HA) S UE- L f rT LIX-D
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 s
on site or within 200 feet of leaching facility) s i Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachingfacility) Feet
Furnished by— - O U/j?9
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