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Commonwealth of Massachusetts
Title 5 Official Inspection Form
r' =_ _ S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
—/� 26 Midstream Drive
Property Address
Elinor Baker
Owner Owner's Name
information is South Yarmouth Ma 02664 3-16-2020
required for every
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 building. Check one of the boxes below:
1=1 hand-sketch in the area below
❑ drawing attached separately
Rear of dwelling
A B
f EVent
0 CI
l3
E--- 60' -------
A1.25' 81-83'
A2-31' 82-73' 1
A3-84' 83-26'
t5insp.doc•rev.7/26/2018 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
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