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The District Health Department
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
i . t '1 Date`
Owner: �"' ,.�, 1,�.! + fi� �iQ r►�,q �w�
Location:�� �
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Contractor: � i -�'-�"1�
Water Supply: Private l. -�'� �blic
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Sewag,�Disposal Facilities: No. bedrooms '� Dishwasher, isposal,
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i washing machir�, other autom�tic appliances f
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� 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 BFrTNSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRIC'i' HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF TH�' INSTALLATION IS COV-
ERED AND PUT INTO USE. r}; �/` -,t �
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Date approved: Signe
f _ Sanitarian
Well: �
Sewage Disposal:
By:
Counter- .
signed
(Owner or his representative)
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Certificate of Comp�e2io� ���
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Date Approved: � By:
Sanitarian �
(OVER)
Location of well and sewage disposal facilities sketched on back. w�
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supglies, 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 lots.
(2)
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