P81968 Hwy 158LOCATION
ADDRESS Z3
PRIVY:
Type
wood
Number
New
Repaired
WATER SUPPLY:
Source
If well, type
(Bored)
42 I/
O 6 (Drilled)
(Dug)
Distance from nearest
pollution /Od ft.'s"
OWNER
----
SEPTIC
TANK: FHA CASE NUMBER
,��u'
Material 4
/
Dimensions D VA CASE NUMBER
Volume
Type secondary
treatment
nitrification line fl ter tre ch
l l S, l✓ta-�+�-
No. of bedrooms /LAJ,Si
Permit Number Date
Approved Date
Approved by�1_ r %��hh•-2�_� %�.cr . /(, C�
Contractor or Plum r
Address
Remarks
SEWAGE DISPOSAL RECORD
Form No. 473 (Rev. 9/58)
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s// r=900-.-- ■■■ r,. O■■ r ■ N■N _ = ■// r. O■■ to o/■ b■
on MEN ii OEM .0 mom on son no won on 1MEN ■■ no now !■■ in" MEN M■■ P"