A27 77;� :
The District Health Department
� Orange, Person.. Caswell, Chatham, Lee C�niies
'I Water �$upp'ly and Sewage �isposai
I' IMPROYEMENTS PER IT� �To.
'I , _ _ . Date � J 1 ' �
I� Owner: �iAv�� S t1utltj .
I Location: ` '
`! �.�� 'f„1.,,>. /13r
Contractor:
Waier Supply: Private �"''� Public
Sewage Dispd's�1 Faciliiies: No. bedrooms � Dishwasher; Disposal,
�, othei automatic appliances
.�_.; �b �r_ f /
"`� 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-
. PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INS ATION IS COV-
' ERED AND PUT INTO USE.
. . _ _ f/, , , r �_
_ , � � �� �._7
^ _
�t�� �LL��i�
� Date approved: — Signe `
� ( Sanitarian
Well:
' Sewage Disposal: Counter-
- - BY. signed
(Owner or his representative)
• 'i
J
Certificate of Completion � `
I �� �"�� i i
Date Approved: Byl
� nitaria
` (OVEft)
Location of well and sewage disposal facilities sketched� on back.�
�
NOTE: Make sketch� of installation showing lot size and shape, location .of house, septic tanks, privies, water
supplies, 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' a,El]acent lots.
\�