P32266 Hwy 601N'�' o l tv
LOC ATION 401n OWNER c/a'� /--Z" /t%
PRIVY: SEPTIC TANK: FHA CASE NUMBER
Type Material
Mood concrete
Number
New
date
Repaired
date
WATER SUPPLY:
Source
If well, type
(Do red)
(Drilled)
(Dug)
Distance from nearest
pollution ft.
Form No. 473 (Rev. 9/58)
Dimensions
Volume
Type secondary
treatment
VA CASE NUMBER
nitrification line filter trench
No. of bedrooms C<
Permit Number Dated
Approved Date
Approved by
Contractor or Plumber
Address
Remarks
SEWAGE DISPOSAL RECORD