A27 53The District Health Department
Orange, Person, Caswell, Chaiham, Lee Counties
Water Supply and Sewage Disposal
I PROV NTS P RMIT No.
Date
Owner: �
Locatio� � U �F
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Cnn tra rtnr �
Wa2er Supplp: Private .�c� Public
Sewage Disposal Facilities: No. bedrooms c�—/Dishwasher Disposal,
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washing machin er a toma c appliances
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-
PROVEU BY A MEMBER OF THE DISTRIC A TH DEPARTMENT
STAFF BEFORE ANY PORTION OF T. INST LATION IS COV-
ERED AND PUT INTO USE. ' � �,
Date approved:
Well:
Sewage Disposal:
By:
Certificaie of Com le2ion
Date Approved:
Counter-
signed
(Owner or his representative)
Location of well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size a�nd shape, location of house, septic tanks, privies, water
� upplies, 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 1 ts.
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