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commonwealth of Massachusetts
Title 5 Official Inspection Form
,;,,--,i, ..,, 14 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
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Owner Owners Name
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Pna. Stata Zip Code Date of Inspection
a System information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal systm, inbluding 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:
1S hand-sketch in the area below
D drawing attached separately
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RECEIVED
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JUL 1 3 2023
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HEALTH DEPT.
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