A40 124The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
.�
s Water Supply and Sewage Disposal
Waler Supply: Private (,.� Public
. Sewage Disposal Facilities: No. bedrooms —� Dishwasher, Disposal,
w�ing machin 'ther automatic appliances
iz 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 an3 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 DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
`
Signed `� 1
5anita ian
Sewage Disposal: � Counter-
BV. . I a.b��..w.
'� (Owner or his representative)
Certificafe of Complefion
r
Date Approved: ��—��pl By: ` �"
nitar an
(OVER)
Location of well and sewage disposat facilities sketched on back.
�
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water