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Commonweaith of Massachusetts
Title 5 Official inspection Form p�-ss Es
Subsurface Sevrage disposal8ystem Form-Not for Voluntary Assessments
47 Diane Avenue
PropeAy Addr�a
Mr.8 Mrs.Arthur Taylor .
; �er Ownera Name
� i"fO""�0n�8 South Yartnouth MA 02664 3l30/10
required for every Cily/Town State Zip Code Date ot Inepectlon
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D. System Informatlon (cont.)
Sketch Of Sewage Disposel System:Provide a sketch of the sewage dispasal system including ties
to at least Mro permanent referen�landmarks or benchmarks.Locabe all weils within 100 feet.
Lxate where public water supply enters the building.
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