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CATION Lc)i O 1-A Q6 -t' Q SEWAGE # !lb -qO-7
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VI1LAGE Wl ac s c3-" ASSESSOR'S MAP & LOT 57— 5'
INSTALLER'S NAME & PHONE NO. Sow Q
SEPTIC TANK CAPACITY yw ya �(olns
LEACHING FACILITY:(type) L (size) C,ydd Lldl��
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER �� S i d ` �d"�5 Co.
DATE PERMIT ISSUED: Ct
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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