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Penni) Issued 1c George Carr 364-0090 Pt(,p.~r~'~. A0dreSs 6003 Shaw Hwy. SE <br /> <br />MARION COUNTY HEALTH 'DEP'P:-Sanitation Specifications <br /> <br /> ................. ~'"~ ................ Si~nature¢ <br /> <br /> RECORD OF INDIVIDUAL SIq'WAGE DISPOSAL SYSTEM <br /> <br />TO Bg COMPLETI~D fly IN~TALL~ <br />INSTALL~:S NAME ,~ ~ddress ~ ~ ~ ~,,~,,,,~ Phone NO~.~ '°~O.~ /~ <br />Tea umbe L vnq ~ ~ ~ Bedrooms ~ <br /> <br />Sepfic f~nk Distance tr~m well ~ ~ ~ M~tet~Gl . ~ ~ <br /> <br /> Tota) liqmd ¢cpo¢lty ~ff f.~ ...... qals <br />Lenq~h et each line <br /> <br />Distance irom: <br /> <br />Re~r []. -: ................. <br /> <br />CLEAN NO 2 BOCK <br />Depth under tile (~ inches <br /> <br />lndic~te Northerly dtrection <br />Ir.;pc~Cti0n ',~dt act be made until completed form is returned to Health Dept <br /> <br /> glqnaturo of Installer <br /> <br />(FOR HEALTH D~T, II~;1~) <br /> <br />Dmsapproved []' <br /> <br /> <br />