A40 105�A�Q-ID� � �o�
The �istr�ct Health Department
O:ange, Person, Caswell, Chatham, Lee Counlies
Water Supply and Sewage D��osal
IMPROVEMENTS PER�IT I��Ta�-
Owner: _
Location:
Contractor:
Water Supply: Private bli
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Sewage Disposal Faciliiies: No. bedrooms Dishwashe��spbs`'dl,
washing_r�ashinP, other auto atic appliances
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Size of tank: ���'���� ����' � Nitrification line: ���'�� �
Other disposal facility: :
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped 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 INSPECTED AND AP-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPAR�MENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By
%�� �
Signe `'> l ` �. s'Ge � �
U Sanit ian �
�-•
� Counter-
(Owner or his representative�
Certificate of Compl 2ion �
Date Approved: _��� U" o �By: `'
itarian
(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 installations may be located
- at later date. Note location of water supplies on adjacent lots.
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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
�
Water Supply and Sewage Disposal
1 IMPROVEMENTS PERMIT No.
Sewage D'ispdsal {Faeiliti
washing machine, other
Size of tank: ! /�/
Other disposal facility:
- �-�w- -
Water supply and sewage disposal facilities ca ion, installatio an
protection must meet state and local regulations.
Septic tank should be pumped 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 INSPECTED AND AP-
PROVED BY A NjEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY POftTION OF THE INST TI IS COV-
ERED AND PUT INTO USE. _ /� n
Date approved:
Well:
Sewage Disposal•
By:.
Certificate of Completion /
Date Approved: � � � �
..
Counter-
signe
(Owne i
�
By: �-
S itarian
(OVER)
Location oi well and sewage disposal facilities sketched on back.
NOTE: = sketch of installation showing lot sizeI shape, location of house, septic tanks, r s, water
supplies, etc. Note special problems existing on lot. Wr1te in measurements in order that installations may be located
at late�ate. Note location of water supplies on adjacent lots.
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