A28 172�e Dis�rict'Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
_ IMPROVEMENTS PERMIT No.
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r� , , Date
. ^ wner: � `' ' �
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Locationr t
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Cnntractnrc • �
Water Supply: Private � Public
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Sewage Disposal Facilities: No. bedrooms `' yD__ishurasher Disposal,
washing machir�e„Jother auto atic appliances c/
'Size o~ f tank-1_ �--!� `--�- � � • Nitrification line: -� `�r" / ^ ,' ,
Other disposal
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 an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and niErification line MUST BE INSPECTED AND AP-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED ANB PUT INTO USE. ,..
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Date a roved: Si ned' .�`" " Lie""'"' `ilc�`'`���Rf`''.J''
PP g r r
Sanitarian
Well:
Sewage Disposal: Counter-
By. signed
(Owner or his representative),
Certificate of Compleiion /
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Date Approved: � By: � - - .
itarian
(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
supplies, etc. Note special:,problems existing on lot. Write in measurements in order that installations may be located