HomeMy WebLinkAboutSeptic As-Built Card Commonwealth of Massachusetts
- Title 5 Official Inspection Form
v Subsurface Sewage Disposal System Poem-Not for Voluntary Assessments
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•77-T , 793 Route 28
Property Address
San i Kansagara _ -._
Owner
information is owners fume
required for every Y�ir .outh ,_____-- _ M,4� 02664 . 3-13-2020 .._..._�.
. page, Citylrown State Zip Code bate 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:
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ASSESSORS MAP
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