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INSTALLER'S NAME &.PHONE NO.
SEPTIC TANK CAPACITY fhU.ST LN
LEACHING FACILITY:(type) Pa-e-_ct4sr Prr (size) lQ6 cl-
NO. OF BEDROOMS _PRIVATE WELL OR Pjjj C WADER
BUILDER OR OWNER i�4►�}}� \ rtr�� a� `.
DATE PERMIT ISSUED: F9
DA T L COLIPLIANCE ISSUED: `7
VARIANCE GRANTED: Yes No
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