P4666 Liberty Church RdLOCATION (
L
�
ADDRESS�� S ��
OWNER- 744
OCCUPANT e
PRIVY:
SEPTIC TANK:
FHA CASE NUMBER
Type
Material
wood
concrete
Number
Dimensions
VA CASE NUMBER
New
Volume
date
Type secondary
Repaired
treatment
`%oo
date
nitrification line
filter trench
WATER SUPPLY:
No. of bedrooms
off.
Source
Permit Number
Date
Ifwell type
Approved
Date
a (Bored)
Approved by
(Drilled)
Contractor or Plumber
( // P _—'��`_c
z�),
wz c
(Dug)
Address
Distance from nearest
Remarks
f
pollution 3ft.
SEWAGE DISPOSAL RECORD \
Form No. 473 (Rev. 9/58)