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SITE ADDRESS: <br /> <br />INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> (to be completed by system installer) <br /> <br />AS-BUILT PLAN OF CONSTRUCTED SYSTE~: <br /> <br /> scale: 1" = ~ ' ~/~7~/ <br /> <br /> ! <br />North <br /> <br />(show all details and dimensions necessary to locate all components of the system in the future) <br /> <br />Sept'~ 'FUnk: Size: <br /> <br />Box(os): [ ] Distribution; [ ] Drop / [~Concrete; [ ] Plastic <br /> <br />[--]'~icensed Sewage Disposal Sezvice <br /> <br />(please print) <br /> <br /> (for Marion County uBe only) ~ · <br /> <br /> system is: <br /> A~proved <br /> /[ ] Approved with corrections: see inspection report <br /> <br />Rev 4/98 <br /> <br /> <br />