110 Dulin RdLOCATION !_ !/��%� �lc�, OWNER "—)�G 1� /�'S/�' ��' �^ X WHITE COLORED
ADDRESS-�� /�- OCCUPANT WHITE l COLORED
PRIVY: SEPTIC TANK: �� , / FHA CASE NUMBER
Type wood concrete Material ���� '�_�'s
Number
New
date
Repaired
date
WATER SUPPLY: / //
Source A47 /� (� // 11 CE? I1-c"C')a11cl
if well, type
(Bored)
(Drilled)
(Dug)
Distance from nearest
pollution :�_� ft.
Dimensions
Volume
Type secondary
treatment
nitrification' line
No. of bedrooms -3
VA CASE NUMBER
filter trench
Permit Number Date
Approved Date V—/" —6 `=
Approved by '• /7 T/1'✓j ��j ,
Contractor or Plumber X
Address
Remarks
SEWAGE DISPOSAL RECORD
Form No. 473 (Rev. 9/58)