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Commonwealth of Massachusetts
,,-i = Title 5 Official Inspection Form
�= ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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Property Address �-_�
owner Owner's Name
information is ):?.-ego-1,-(t‘
/1/J/ ��57.43
required for every �/� �/4 iQ 0201
page. C'tyrrown r
State Zp Code Date of Inspection
D. System Information (cent.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system; including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
L_I nand-sketch in the area below
_j drawing attached separately
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LFraGaco-rev.7/2620-8 .._5 C.^.'..d lespez.,rcn h. Su=urface Sewage Zisposal Syvem•?age 16 of 18
RECEIVED
JUL 13 2023
HEALTH DEPT.