P1968 Gladstone Rd' LOCATION OWNER C� �L��=`'"
PRIVY:
f
SEPTIC TANK:
FHA CASE NUMBER
Type
Material` -
wood concrete
Number
Dimensions
VA CASE NUMBER
New
/
Volume
date
i
Type secondary
Repaired
date
treatment
nitrification line
filter trench
WATER SUPPLY:
3
Source
No. of bedrooms
Permit Number
Date
If well, type
Approved
Date
(Bored)
Approved by
-✓ (Drilled) �j"
Contractor or Plumber
(Dug)
Address
Distance from nearest
Remarks /CAP" �/u �<
pollution 5-0 ft.
3
SEWAGE DISPOSAL RECORD
Form No. 473 (Rev. 9/58)
0�
.1 3 b C) (