P2766 Liberty Church RdLOCATION Pr I �,/� OWNER v4�/e-s v re N
PRIVY: SEPTIC TANK:�.FNA CASE NUMBER
�c
Type Material /'e r axcre
wood concrete
Number Dimensions
New Volume
date
Repaired Type secondary a
date treatment
nitrification line
WATER SUPPLY:
No. of bedrooms
Source
If well, type
(Bored)
(Drilled)
(Dug)
Distance from nearest
pollution ft.
Form No. 473 (Rev. 9/58)
VA CASE NUMBER
filter trench
Permit Number Date ���.,� ,,
Approved Date ��
Approved by-uc—E
Contractor or Plumber'fW;,s ro s �
Address
Remarks
SEWAGE DISPOSAL RECORD