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The District Health Department
Orange, �Person,ti Caswell, Chatham, Lee Counlies
Water Supply and Sewage Disposal
IMP OVEME�T PERM� T o.-�'/
� /1 L� � h .:�ate `'�1 =�.,F�
Owner: - ' — ���� � � �:.
��at, �
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Water Supply: Private lf� Public
/3eW►a3e�isFnss�LFacilities: No. bedrooms "'"'' Dishwasher, Disposal,
( washing machine, other automati appliances /
Size, of tank: r• � Nitrification line: r
l �
, f . / �
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 INSPECTEB AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR.TMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date a!lroved:
Well:
Sewage Disposal:
By:
/�'� �'� -
Signed .L! �� ,1 �'i''`�'. f�
Sanifarian
Counter-� , i,- � ; ; ( ,
signed ' " ` ; �
(Owner or his representative)
. . ,,. f^
. ��
Ceriificale of Co ple2' n / `
kJf � tl
Date Approved• �, � By. +� ` ,
Sanitarian '`
(OVER) '
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
� su�aplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
- .at later date. Note location of wat�supp�'�n adjacent lots.
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PERSON COUNTY HEALTH DEPARTMENT
355A S. MADISON BLVD.
ROXBORO, NC 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant � i C%r�e I -r�lrler�
Address�� j� �m . � County �r��►'�
Collected By��
Date Collected I( L�� 1� Time Collected J�: �� � M
Source: LiWell
0 No Charge
❑ Spring ❑ Well Tap ❑ Other
�" Charge
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���*��������������t���������*��������*�����������*�*�����������c����������
Total Coliform
FecaVE. Coli.
Results
Present Absent
D �V
o �
Reported By ,
Date
IIIb�112�