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Septic tank:: Minimum liquid copocd~, wilh distribution box__ <br /> <br />Subsurface Disposal Field,,~lc,.~ ,,~r~"quired / ~_..Lin <br />Lot <br /> <br />Issued by: <br /> <br /> Record Of Individual Sewage Disposal System <br />To Be Completed by Installer <br /> <br /> g <br />Total number: Living units .... ~ 8edrooms_~g-iL,~Baths ,/ Basement:: Yes ~] No ~- <br />Water supply Public system ........ Indi'.,idual well----/(__Community system _ <br />Septic tank: Distance from well ~"'O feet Material __ No of compartmenis ........ <br /> <br />Total liqud capacily ~ C~_~, ¢--' .gal Inside length <br /> Diameter ,,ft Liquid depth <br />Tile disposal fie]d Distribution box? Yes'~ No [] <br />Length of each llne <br />Total length of aH hnes___ f ~(~ ! ft <br />Widlh of trench ~,) .1.~. .... ft <br />Total square footage ft <br /> <br />Type of fiber materiel: Grovel ~_.:' ~. l~,~.~Other <br /> <br />Depth of filter materiel over tile .... _.~ <br /> <br />_~ ....... _' ft <br />Other <br /> <br />inside ~idth ...... ~ fl <br /> <br />3ketch of installaho'~----' ~ <br /> <br /> Distance froffl:: [ <br /> Wdl_ .~.0 ft <br /> <br /> Lot line Front [] Side [] Rear [] ft <br /> Foundation .ft <br /> Depth beneath tile, ~.~ inches <br />inches Depth O[ tiJe below original ground surface ,~O,,/ ~nches <br /> <br />Note <br /> <br />Indicate Northerly d~rection <br />Inspection will not be made untd completed form is returned to the Heahh Depl <br /> <br />OATE__. !0-,,~)'ff- (,, ? <br /> <br />System opporentJy wdl l~ will not [] <br />Remarks <br /> <br /> Signature of Installe~~ <br /> (FOR HEALTH DEPT USE) <br />function satisfactorily and is therefore opprove~ Disapproved <br /> <br />Copies: !1) Orig,, HD Fdes <br /> <br /> <br />