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LG^ATION S V �ZfZ SEWAGE# �o®g
VILLAGE C—U OA�Ow i�Rlt ASSESSOR'S MAP & LOT '3S2-/3-/
INSTALLER'S NAME&PHONE NO. 61L'LE's &?o s - COyS78,,
SEPTIC TANK CAPACITY I.
LEACHING FACILITY: (type) �� � (size) _/0 X 1/40o 9X
NO. OF BEDROOMS
BUILDER O OWNER `�E� 4 aA, R� l t�-)
PERMIT DATE: ' LAP I. COMPLIANCE DATE: -7 " Z C
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exisi
on sitesor 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
(3 Utz.
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