HomeMy WebLinkAboutSeptic As-Built Card • Commonwealth of Massachusetts
*.' Title 5 Official Inspection Form
,� r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 39 Violet Glen Road
Property Address
Kenneth D. Keim
Owner Owner's Name
Information is
required for every South Yarmouth Ma 02664 3/02/2020
page. 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 ilding. Check one of the boxes below:
hband-sketch in the area below
❑ drawing attached separately
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t5inep.doc•rev.7/28/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18