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Date. 10-7-71 <br />Permit lssued lo~.~arl°we Fazo~ 364-5219 <br /> <br />Septic tank: Minicnum liquid capacity with distribution box ......... <br /> <br />Subsurface Disposal Field r~quired ~ Lin ff ~.'__Widlhoftrench <br />Lot survey <br />Other <br /> <br />Issued by: <br /> <br />.sq. ft <br /> <br /> Record Of Individual Sewage Disposal System <br />To Be Completed by Installer <br />INSTALLERS NAME ~-~--v-~:-~-¥''~ ..... Phone No, ~' ~'-//~ Address <br />Total number~ Living units /~ .......... Bedrooms~ ,, Baths ~ Basemenh Yes [] No[~ <br />Water suppty: Public system Individual well ___~__ CommuniJy system <br />Sephc tank:: Distance from well ..... /~ ~ feet, Material ~..~..,~7- e No of cempartments_....~ <br />Totalhquidcapacjty .... _/~,~i~ gal Inside length ,~'~'-~' ~'- fl, inside width ft. <br /> Diameter ft,, Liquid depth, ft. <br />Tile disposal field, Distribution box? Yes ~ No [] Other .~ <br /> <br />Length of each line /~/~ <br />Total length of ali lines <br />Width of trench <br />Total square footog~ <br />Distance between lines <br /> <br />ft, Well ~¢ ~' ft <br />ft, Nearest <br />ft. Lot line~ Front [] Side.[~ <br /> <br /> Fou ndotlon_.~.~..~ / ft, <br />Type of filter material:: Grav,~l; ............. Oth~r Depth beneath tile inches. <br />Depth of filter material over tile ~'~-' inch~s Depth of the bel~ original ~round surface <br /> <br />k~tch of in~[611alion <br /> <br />Indicate Northerly di~,*~-- ~-~'~'~ <br />~nsp~ction will not be made until completed form is returned to the Health. Dept <br /> <br />System apparently will ~ill not [] <br />Remarks <br /> <br /> (FOR HBAL'rH DI[pT. <br /> <br />function satisfactorily, end is therefore approved '~-" Disapproved [] <br /> <br />Date / <br />Copies: (1) 0 le <br /> <br />(SANITARIAN) <br /> <br /> <br />