P1973 Jack Booe Rdr—
LOCAT ION �d PJ OWNER F40JQ )r v
PRIVY: SEPTIC TANK: CqFHA CASE NUMBER
Type Material i Ire 4
Wood concrete
Number Dimensions pt Q =$Z BER
New Volume G�
date
Type secondary
Repaired
date treatment r l
nitrific line
WATER SUPPLY:
No. of bedrooms
Source
If well, type
v� S{ (Bored)
(Drilled)
(Dug)
Distance from nearest
pollution A00 ft.
/5-b (' �4r
filter trench
Permit Number Date
Approved Date
Approved by qq
Contractor r Plumber
Address
Remarks
c
C
SEWAGE DISPOSAL RECORD
Form No. 473 (Rev. 9/58) .