P111565 BaileyLOCATION &- � OWNER ysc��
PRIVY: SEPTIC TANK: FHA CASE NUMBER
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Type Material dzL / O
wood concrete ,+.
Number
New
Repaired
WATER SUPPLY:
Source _
If well,
type
(Bored)
_ (Drilled)
(Dug)
Distance from nearest
pollution ft.
Form No. 473 (Rev. 9/58)
date
date
D / r
Dimensions
Volume
Type secondary
treatment
No. of bedrooms
Permit Number
Approved
Approved by
oP v�
nitri cation line
Z11—
Contractor or Plumber
Address
Remarks
SEWAGE DISPOSAL RECORD
VA CASE NUMBER
filter trench
Date J
Date