P42966 Deadmon RdLOCATION '� {/• OWNER ( �C 'l 'z -"'
PRIVY: SEPTIC TANK: FNA CASE NUMBER
Type
Number
New
Repaired
WATER SUPPLY:
Source
wood concrete
date
date
If well, type
(Bored)
(Drilled)
(Dug)
C
Distance from nearest
pollution ft. �!!
Form No. 473 (Rev. 9/58)
Material
Dimensions
Volume
Type secondary
treatment
nitrification line
No. of bedrooms
Permit Number
Approved
Approved by
VA CASE NUMBER
filter trench
Date �'-2 �—/
Date
Contractor or Plum¢er ~J
J
Address
Remarks
SEWAGE DISPOSAL RECORD