A40 146The District Health Department
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CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMI N�., r
�/ Date
Owner: v � S e . � � �
Location: _
—� � -
Contractor: � j�i� � � -
Water Supplp: Private —�� Public
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Disposal,
washing machine, other auto�natic appliances
Size of tank: � � <<`�� � Nitrification line:
` 1 , .y v^V
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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
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Date approved: - Signed ,
Sanitarian
Well
Sewage Disposal:
By
Counter-!„�.t}-�n • (►,��%�
signed �ti�c.��r`..-r'�^• t�P
(Owner or his representative)
Cerlificate of Completion %
i � ;� ��
Date Approved: ��B .
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back