A36 13� The District Health Department
Orange, Person, Caswell, Chaiham, Lee Counties .
y
�Q
7 �' Water Su ply and Sewage Disposal
� �nne � �v�a � �- ; � -'7
� ` �at
� o Owner: � r �
� .�f {Lo���oi�' � „ _
� Cih � x ,i�.
' � v
a
Contractor: � �`��
�n
� Water Supply: Private Public
Sewa e Dis osal Faciliiies: No. bedrooms Dishwasher, Disposal,
washing machine, ther autom tic appliapces ��
5ize o tank: Nitrification line:
� � _ _� ��
Other disposal facility: �
Water supply and sewage disposal facilities location, installation and � e
protection must meet state and local regulations. ''
-3
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PAftTMENT STAFF before any portion of the installation is covered
and put into use. -
(OVER)
�.
Location of well � and sewage disposal facilities sketched on back.
; � �
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that instailations may be located
at later date. ,
(1J �' (Z)
�.