P12165LOCATION
ADDRESS
OWNER ``��"%�2-1
OCCUPANT /�-1 �� ` `t /k
PRIVY:
SEPTIC TANK:
FHA CASE NUMBER
Type
Material
Mood
concrete
r
Number
Dimensions
��'� "� ^'�
VA CASE NUMBER
New
Volume
date
Type secondary
�D
Repaired
treatment
date
nitrification line
filter trench
WATER SUPPLY:
No. of bedrooms
Source
Permit Number
Date _
If well, type
Approved—T-7777Date
Q
(Bored)
Approved by
-
(Drilled)
Contractor or Plumber
Y
(Dug)
Address
Distance from nearest
Remarks
pollution ; ft.
SEWAGE DISPOSAL RECORD
Form No. 473 (Rev. 9/58)