P7566 Hwy 601SLOCATION OWNER
PRIVY: SEPTIC TANK: FHA CASE NUMBER
Type Material
wood concrete
Number
New
Repaired
WATER SUPPLY:
r �+
Source
If well, type
✓ (Bored)
f
(Drilled)
(Dug)
3
y 3- Distance from nearest
pollution ft.
Form No. 473 (Rev. 9/58)
date
date
Dimensions
Volume
Type secondary
treatment
No. of bedrooms
VA CASE NUMBER
nitrification line filter trench
Permit Number Date
Approved Date
Approved by
Contractor or Plumber��
Address
Remarks
SEWAGE DISPOSAL RECORD