TOWN OF PLYMOUTH
11 LINCOLN STREET, PLYMOUTH, MA 02360
BOARD OF HEALTH
508-830-4090
SEPTIC SYSTEM AS-BUILT REQUEST
DATE:______________________________ FEE: $10.00___________________________
DATE PAID
_______________________________________________________________________________
NAME OF APPLICANT STREET TOWN ZIP
TELEPHONE NUMBER_______________________________
CIRCLE ONE:
DO YOU WANT TO PICK UP RECORDS OR HAVE RECORDS MAILED?
MAILING ADDRESS____________________________________________________________
STREET TOWN ZIP
SEPTIC RECORD REQUESTED:
_______________________________________________________________________________
STREET MAP LOT
DO YOU NEED SPECIFIC INFORMATION COPIED?
___________________________________________________________________________________
___________________________________________________________________________________
THIS SPACE FOR OFFICE USE ONLY
DATE PICKED UP___________________________ DATE MAILED___________________________
|