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1NS'ALLER'S NAME & PHONE NO,
SEPTIC TANK CAPACITY_ L�Zr+�
LEACHING FACILITY:(type)' �` ; (size)_
NO,OF BEDROOMS Y PRIVATE VELI. OR PUBLIC WATER
BUILDER OR OWNER� ��5
DATE'I'ERMIT ISSUED: 4 ��
DATE-'.COUPLIANCB ISSUEDi
'VARIANC - GRANTED: Yes No
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