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� � � Commonwealth of Massachusetts
Title 5 Official Inspection Form �( (�
, Subsurtace Sewage Disposal System Fortn -Not for Voluntary Assessments
25 Vacation Ln
Property Address
Aditi Joshi
Owner Owner's Name
iniwmation is Y8f7T�outh MA 02664 5-7-15
required for every
page. ��YRa'r+� State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two perrnanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the tmxes below:
� hand-sketch in the area below
❑ drawing attached separately
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pecfian Form:Subwrface Sw,aga Dsposal u�m•Page 15 of 77