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INSTALLER'S NAME & PHONE NO. AVOTT6 CGA6 ,
SEPTIC TANK CAPACITY /000
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NO. OF BEDROOMS— _PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 66C�RCE 13(10W,EA,
DATE PERMIT ISSUED: 6-3c) $-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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