A28 138_ � �. .
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply ond Sewage Disposal�
IMPROVEMENTS PERMLT I1T .�_�
Dae ���� � '
^— •
Owner: �
Location:
,, . _ � � �_,.� ,
-;-
C� - , �
'� ,� %" � - ,
�� 1' � Contractor: .�.� � ^ti=- •— (i
!�� Watez Supplp: Privafe ���/ � Public \ �
-, , ,� , �.
,. ,
, , .
' , ; -
,, :
; -� i :�_ j � � i � � ,.� �i � � y,.� - •. : n �� ( � �j __
,�._� � ! ����� ;/ �� . i� ��-;%'� �:�,,.�
Sewaqe Disposal Facililies: No. bedrooms � Dishwasher,
,
washing machin otheF; sutomatic appliances
Size of tank: �'� Nitrification line:
� , . _ ► i
�ther disposal facility: '-' � ' '
ater 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 HE�LTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INS� ALL�ATION IS COV-
ERED ANB PUT INTO USE. � �,. �
%r�i � !� �-r----
I �J� 1.f,,:.( � ���� �,� �
Date approved: Signe� _ �,'� � '��
Sanitarian
Well:
q � .
Sewa e Dis osal: � �' ��( � ,�
g P Counter- ll.�,, ,_� tii�a��J ►, ,.:�h
BY• 9igned - _-
(Owner or h' representative)
�estificate of Com letion � �
� � �
�ate Approved: '� By:
nitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.