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ccord Of Individual Sewage Disposal System <br /> <br />To Ese Completed by Installer <br />Total number, Living units .Bedrooms ~,~b~Baths _~.,/ Basement:: Yes [~ No~- <br /> <br />Water ,~upply- Public s~stem ........ Individual well __L Communily system .... <br /> <br />Septic lank: Distance f~om well .~O . .__Jeer,, Material ..... No- of comportrnen~ ......... <br /> <br />Total llqu~dcopoclly ~ ~ C~ ,gal. Inside length <br /> DJometer~ ..fi Liquid deplh ,~.__ ' <br /> <br />No [] Other <br /> <br />ft Distance from: / <br />__ ft WoU <br />fi,, N~orest <br />fl LOt hne Front [] Side[] <br /> J:ou r~dalion__ It <br /> <br />Rear [] ft <br /> <br />Tile disposal field Distribuiion box? <br />Length of each llne <br />Tatar length of <br />Widlh of trench ,.~ 4-~.~ --- <br />[Dial equate footage , <br /> <br />Deplh of filter material over hie _. _ _~ inches Depth of tile below original ground :~urfore <br /> <br /> 4ate Indicate Northerly direction. <br /> Jnspe¢tion will not be mode until ~:ompleted form Is returned to lhe HeaJlh- Depl. <br /> <br />DATE__. ! O %~) ff - (~ '7 Signature o~ <br /> <br />,w;lt not [] <br /> <br /> (FOR HEALTH DEPT. USE~) <br /> <br />function $olisfarfaril¥ and is therefore apprc,,.'ed~ <br /> <br />Disopproved <br /> <br />Copies: !1 Orlg,, HO Files <br /> <br /> <br />