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-uu.I, i;cr/.. amm.on 3peat,cartons <br /> .. - ~ N~mber. .. <br /> <br />Per~H issued To~ ~niS viet~e .... ... ~operly Addres~s A~vIll~ <br />S.pJic tank~ Minimum liquid capacity wllh disJribution b~ ..... Gals, <br /> <br />To Be Completed by Installer <br /> <br />folol number: Living unit~ ..... <br />waJer suppl~ Public system .... I~ivldual well ~ _Community ~ystem <br />Seplie ta~k: PI,lance from well~ ~ _loot. ~terlol <br /> <br />fatal liquid <br /> Diameter <br />Tile ,'llsposol field: Distribution <br />Lenglh of each line <br />TO~Ol length of all <br />W~dlh o~ trench .... <br />rolal ~uore <br /> <br />Depth of filler mater,,iol~_ over lile .... <br /> ~ketch of in¢ollotlan. ~.,~T,~--- ~ <br /> <br />.gol. lnslde length h. Inside width__.__ f <br />Liquid depth fl. <br />~' No I~ Other ...... <br /> <br /> ...... ff. we~l ..... <br /> <br /> ~ ft. Lot linm Pro~l ~ Slde~ Rear ~ <br /> Fou~atlon ft. <br /> Other .... De,th beneath iile~inchet. <br /> .~inches. Depth ~ tile bel~ orlgl~l g~und surf~e <br /> <br />inches <br /> <br /> Indicate Northerly dlrecflon, <br /> Inspection will not be mode ualJ~ completed form is returned to the H~hh, Dep~, <br /> <br /> (FOR H~LTH DE~, USE) <br />System oppOrantly will~ will not ~ <br /> <br />funcllon t. ottsfactorily, and is Iherefore appcoved/J~ Disapproved [] <br /> <br />Cap, es,; (II Orig. HD Film~ <br /> <br /> <br />