A27 711�� ` a
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age Dis�
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Size o anl+
, . The � District Hea.lth Department _
Orange, Persori;' Caswell, Chatham, Lee Couatiea
Water Supply and Sewage Disposal
Z ' ��� PE�I , No . � . , :
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Owner: ,
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Loca�i ; - " _ ' ' ,
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Contractor: � r" �����'�
Water Supplp: Priyate �"`��~~^ Public
No. bedrooms '—L� Dishwasher, Disposal,
tomatic appliances
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Other disposal facility: �' � `� � � � '
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Water supply and sewage d3sposal facilities lo�tion, installation and �
protection must mee4 state and local regulations. ,
5eptic 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 INSPECTEB AND AP-
PROVED BY.A MEMBEft OF THE DISTRICT HEALTH DEPAR.TMENT
STAFF BEFORE ANY PORTION OF THE ,INSTALI.ATION- I5 . COV-
EFtED ANI3 PUT INTO USE. �
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Date approved• Signed ' f '�' <� s t' •-,
Well• � �� Sanitarian�`
Sewage Disposal• Counter- - '
signed ', ;;� . r-,
By' (Owner or his representative)
._._�.._.......
Certi�cate of Compleiion ?+, '
Date Approved��� B `� , t ,�
Y� � ' :-.
Sanitariari
(OVER)
Location of well and sewage disposal facilities sketched on back.
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