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INSTALLER'S NAME & PHONE NO. // //� i/ �iOGo/nIIGP v� i✓
SEPTIC TANK CAPACITY ��oo
LEACHING FACILITY:(type) l / (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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