A37 20>�C. i :rt`.Na.:�c - � �s 1�. � .. � ....
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� _p: .. ,.The�sDistrict,-Health:�„Departmen�t
��,. � � : Orange, Person,�. Caswell, Chatham, Lee Couniies'
:.-� " . .
� �-,� Water Supply and Sewage Disposal
% ' IMPROVEMENTS PER T. o^�
� � a �'-:. � lay�� � ,� - Date —
i�-� u' ��i��.-1 i� � Owner: r? , y
i `. ,,� c
( . � �� pq Location: •/ � '. " _
,}".� l../C� �AM...9� • � �� .�
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/y r�.�r - . �J
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, p, Contraetor: _ 1 t�t./
, �n
� Water Supply: Private — ~/ Public
. . !
acililies: No. bedrooms ��Di—'s� asher�Disposa�l,
'_-------.-.� �:
ashing machine other automatic appliances *'
•'� •� f / � �/
-Size of tank: } Nitrification line• '•
, / �� , � /
. 'Other disposa� facility-: - " " �- ' � "' � C�
- ,_ �. . " �. • .
•`.* •• Water supply and` sewage 23isposal facilities' location, installation .and
protection must .tneet state and local _ regulations.
5eptic tank should be pt.imped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
-� Septic tank and nitrification line MUST BE INSPECTEI3 AND AP=
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
. ERED AND PUT INTO USE.
' r''� �� - -
. Date approved: — Signe �' �
Sa itariazf •
- Well:
Sewage Disposal: � Counter- , • �---"'—
signe -
BY� . i � �
. . � -1 �f � �
,
CerYifica2e of Completion � � - � � , /�.
/ ;' �
Date�ApProved:�. �" �� By;!/l ,'�J.,� l, :� i'.
� , . `��anitarian =
, � • ._ . (OVER) , . f
Location of well ,and. .sgwage 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 installations may be located
at later date. Note location of water supplies on adjacent lots.
/
(Z)