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m <br /> <br />On-Site Sewage .Disposal System <br />Location and Maintenance Report <br /> <br /> Name <br />m Address <br /> Subdivision name <br />m Type of Septic system (circle) <br /> <br /> 1L Septic tank - dratnfield <br /> ~. Septic tank - seepage pit <br />m <br /> 3. Cesspool <br /> 4. Privy <br /> 5. Other cdescrtbe) <br /> <br />m <br /> <br />m <br /> <br />Lot <br /> <br />P.I.N. <br /> <br />Septic Tank Inspection <br /> <br />Scum .--"' ]- -- <br />Sludge layer -. <br /> <br />m Distance "A" inches <br /> Distance "B" tnch~s <br /> <br />CLEAN OUT TANK when: <br /> <br />Yes No <br /> <br />"A" is 3" or less <br />"B" is 12" or less <br /> <br /> 1 as~:/pi~mped . m ....... <br /> · ~ 'v '-"? :: ;" '., ~ ~" :~ -./~:.. .- F '. '._ <br />.owner 7 'Inspector.~.· Signature . <br /> <br />Date <br /> <br />Oate <br /> <br />Location of Septic System <br /> <br />Draw your lot, house and <br />outbuildings, water well, <br />and septic system loca-':, <br />tions on the grid. Use <br />dimen ions in feet. <br />Please locate septic tank <br />riser{s) by distance from <br />corners.,of the house to <br />riser{s). Show north <br />arrow and direction of <br />slope on lot. <br /> <br />Block <br /> <br />Date of initial installation (if known) <br />Date of last repair or reconstruction.ofsystem (if known) <br />Has sewage ever backed-up into the house? Yes No <br />Has effluent ever surfaced on the yard from the drainfield? <br /> <br /> <br />