P111964 Milling RdFc& r„1&r9, �%
LOCATION / � �`� r OWNER � aL�ckr
PRIVY:
Type
Number
New
Repaired
wood concrete
WATER SUPPLY:
Source 6?`
If well, type
(Bored)
(Drilled)
(Dug)
Distance from nearest
pollution ft.
Form No. 473 (Rev. 9/58)
date
date
SEPTIC TANK: FHA CASE NUMBER
Material JtC he - t N i4sl�
Dimehsions
Volume o7
Type secondary
treatment
VA CASE NUMBER
SEWAGE DISPOSAL RECORD
nitrification line
filter trench
No. of bedrooms 3
Permit Number
Date
Approved
Date
Approved by
Contractor or
Plumber
�oa�IeNhiee
Address��
Iii, /6-5'42
its
Remarks c*C/ cL/
Q e
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f{aure r
SEWAGE DISPOSAL RECORD