HomeMy WebLinkAboutInspection Report 1996 Oct 03 � U � �
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j � BOr1RD O [= H EALTH �
�' R�QUFST FOR SEPTIC SYSTQ7 INFC7[2MATION
(E'ORM MUST BE FULLY OOMPLETEp)
l. LOCATION OF INSPECTION: �l {����Q,(�O I�x ll1C Q,(�rY�j��-
2. TOWN ASSESSOR'S MAP # � (3 , LC� #�'� �j
3. DATE HOUSE WAS BUILT:
4. WELL ON PROPERTY, INCLUDING IRRIGATION WELLS? YES NO
(SHOW LOCATION ON SEPTIC INSPECTION FORM. )
5. OWNER'S NAME AND ADDRESS: ( � �
_ �,0 -1��X �i-�'�
�'.hn�.r I�rn � rn�1
6. BUYER'S NAME AND ADDRESS:
7. OTHER INFORMATION REQUFSTED:
The Health Department wi11 provide:
1. Last four (4) years of septic pumping history;
2. Septic system location "AS-BUILT" card, if on file;
3. Septic system description;
4. Copy of Septic Disposal Application;
5. Percolation card, if on fiie (New houses since 1980);
6. Review of engineered septic plan, if on file.
ALLOW TF�T (10) BUSINESS DAYS FROM DATE OF SUHMITTAL FOR TI� HEALTH DgpARTMH�gr �p pROVIDE �
II�'ORMATION RHQLTFSTID. �
ON CAP�L►_.T�.'ED SEPTIC II�LSPECTION F�ORM� AZ'PACH "AS-BUILT" IACATION CARD SUPPLIED BY THE `
HEALTH DEPARTMENT.
MAP AL+ID LAT NUMBIIt MUST ALSO BE PLACED ON THE FRONT PAGE OF THE INSPFCrION FCIRM.
HIGA GROUI�IDylATII2 (JSII�JG THE USGS GROIJDIDWATER ADJLT3�Tp FpRMUI,A MUST BE USED AND SHOWN ON
THE FORM. (OOPIFS OF �ORMEILA MAY BE ORmArt�t?n AT THE CAPE OOD �ISSION� 362-3828.)
NAME OF STATE CERTIFIED SEPTIC INSPECTOR: � ����
�D�ss: �l-u� M i r --`T ��V
r�nc�, rn�a ��t o�3
TELPHONE NUMBER: r��l-�� Q -�(�] '
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FILING FEE OF $10.00 PAID ON: -� ,
� - ; Printed on ,
Rec��cied
09/21/95 Revlsed � � Paner