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� Commonwealth of Massachusetts
: Title 5 Official Inspection Form RECEIVED
_ a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments DEC !�� z,���
M �•� 53 Grandview Drive HEA
Property Address -
i
Tim Sullivan
Owner Owne�'s Name
information is South Yarmouth Ma 02664 10/06/2017
required for every
page. CitylTown 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 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:
❑ hand-sketch in the area below
i- - [{-�rawing attacqed separately __ ___
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t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17