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Commonwealth of Massachusetts ' s h oI
�- �� , Title 5 Official Inspection Form J�,�,ai1, m, Izl�(
I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,
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Property Address
Damon Burehill & Brenda Stein _ _
Owner Owner's Name
information is West Yarmouth _ Ma. 02673 6-24-22 —
required
ge. for every City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
® hand-sketch in the area below
❑ drawing attached separately
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
l5insp.doc•rev.7/26/201e