CooleemeeOWNERv
LOCATION ail n �'✓U 4TE
ADDRESS l `'�; OCCUPANT _ WHITEy
PRIVY:
Type
Number
New
Repaired
wood concrete
WATER SUPPLY:
Source 01
If well, type
(Bored)
(Drilled)
(Dug)
date
SEPTIC TANK:
Material
COLORED
COLORED
FHA CASE NUMBER
fr /
Dimensions w VA CASE NUMBER
Volume �c�/••= Q.t ` Ntn d
Type secondary ,
treatment�%� S�
nitri at/on line filter trench
No. of bedrooms
Permit Number
Approved
Approved by
Contractor or Plumbe re—�
Date 7
Date
Address
Distance from nearest
Remarks /'C' •e -09u71- 'e,A4i r
pollution zon ft. F�/ti S•1 % Jr
l/X �i/ c'j� yt f? tt �G.5 /YG f �c'.�il �t(l 2 r, r G
SEWAGE DISPOSAL RECORD
Form No. 473 (Rev. 9/58)