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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
Date � — �n �-S
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Owner. �*L�Qy � kt�,X
Location:
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Water Supplp: Private L" Public
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Sewage Disposal Facilities: No. bedrooms Dishw�sher/
washing machine, other autor,�atic appliance��
Size of tank: ��1(�l� c�f' NitriBcation line: �i����
� ther dispo al facil' vY ` �ry ��� � �
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ater supply and wage disposal facilities location, installation and
p tection 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 DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. /J „ _
Date approved:
Well:
Sewage Disposal: "
By:
� �-Sanitai�i ;
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Counter = �� "?/:` �/ !
aigne �" ' j ,
(Owner or�his, repre�entative)
Certificate of Completioa �
Date Approved: � � By:
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
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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. WrSt.e in measurements in order that installations ma be located
_ _ __ .__...
at later date. Note location of water supplies on adjacen� lots. !1 /' .� �
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