A27 51� �
1'he Disfric#� Healfh Departmenf
Orange, Persoa, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
, Date ���-1n._.;��
Name of owner: .�_I.
Name of contractor: _
Address and Directions
��
Person or fum doing installation: � �- �- �
Address -
No. of persons to be serve� Bedrooms 1, 2��.
Additional appliances to be used: Disposal, dishwasher, washing
machine
Recoxnmended• Septic ta � r
Nitrification line: � �(,d ��
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the Disfrict Health Department sfaff before
any portion of the installation is covered.
,
Date Approved: � . `�.�� - �j �
By:
Countersigned
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
SUGGESTED INSTALLATION (Date ), FINAL INSTA7 LATION (Date )
(Road or Street) ,� � � � ,� (Road or Street)