P9469 Hwy 601NLOCATION OWNER
PRIVY: SEPTIC TANK: FHA CASE NUMBER
Type Material
wood concrete
Number
New
Repaired
WATER SUPPLY:
Source /, a Dg �m
If well, type
�- (Bored)
(Drilled)
(Dug)
Distance from nearest
pollution S0" t.
Form No. 473 (Rev. 9/58)
Dimensions
Volume
date
Type secondary
date treatment
No. of bedrooms
Permit Number
Approved
Approved by
19
nitrifica, o i n e
-7—ra "/! r
Contractor or Plumber
Address
Remarks
K
SEWAGE DISPOSAL RECORD
VA CASE NUMBER
filter trench
Date
Date