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~o z2-72 MAKIUfl LUUflI! UIzA'izl't'l~Dl-I"l. -3amtahon ~pec~hcaho~ <br /> <br /> Permillssued To. C. $. Sch,L"ine~ 76D,.-~,~.04 <br /> <br />5epHc ~ank: Minimum llqvid copac~l~ wi~h dislHbution box ~ Gals <br /> <br />Other teqvlrement~ ~n~, <br /> Record Of Indi dual wage d System <br /> <br />Water suppiy~ Public system individual well ..... .~-~Community system <br />Septic t~nk: Dlslonce f~m well /~ ~ ,~JeeL Mater,al ,~/ _No. of compartments <br />Total liquid Copocity~~ ~ .~gol,, In~ide length ~fl. inside width. <br /> <br /> Diameter ....... it. Liquid depth ...... ft <br />';il. dispos. I field, DIstr~b,?i,~9_box? e~s~[~ No ~ Other <br />Length of eoch line. <br />Total length o~ all Ilnes~ ~ / ~ fl. Distance from: <br />Width o¢ treneh~ fl, Well~ <br />fota~ ~uore footo~ · ~ , ft Nearest <br />Distance between lines ........ <br /> <br /> '~ ~, .~, Foundation /~ fi. <br /> <br />Depth o~ filter material over file ~ inches. Depth o~ lile bel~ original ground surface~, inches <br />~ketch of installation,, ' ........... <br /> <br />~ote l~d~cate Northerly d[recl~i~7 <br /> Inspection will not be made until completed form is returned to the Health. DepL <br /> <br />System oppo,enfly will [~will not [] <br /> <br /> Signo,ture Of InaR;ller n ~, <br /> <br /> IFOR HEALTH DEPT. USEr <br />~unclion S0tisfaclOrily. and Is therefore appeared [~Disapproved ~ <br /> <br />Remark~ .__ <br /> <br />Copies~ (fi Orig. HD Files <br /> <br /> <br />