350 W Church StLOCATION�`�� OWNER �—
I r a �R
PRIVY: SEPTIC TANK: FHA CASE NUMBER
Type Material re4
wood concrete
Number
New
Repaired
WATER SUPPLY:
Source "6(NrCr
If well, type
(Bored)
(Drilled)
(Dug)
Distance from nearest
pollution ft.
Form No. 473 (Rev. 9/58)
date
date
Dimensions
Volume
Type secondary
treatment
No. of bedrooms
9o0 �Z
nitrifi edtion line
3
VA CASE NUMBER
filter trench
Permit Number Date
Approved Date 6!0
Approved by ,
Contractor or Plumber
Address
r,
Remarks �oc c(, r'BccJn GrGde NQ rte(
-T 1 -H6 -/Q ,�. T. -� N,-6 bed.
I ped eA% �'d A
SEWAGE DISPOSAL RECORD