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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
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Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
�.._--^• Date � - -�—
Owner: � � n')..!� �'1� Y1a.0 �.
I.ocati :
Contractor: ��1Cj
Wate: Supplp: Private � Public
Sewage Disposal Facililies: No. bedrooms I
washing machine, other automatic appliances —
Size of tank: ^ �i� � � � �<. * Nitriftcation line:
Other disposal facility:
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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 nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT H LTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE Il� ALLATION IS COV-
ERED AND PUT INTO USE. i �
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Date approved: Signe� � � �� / �" "�"« �
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( Sanitarian
Sewage Disposal:
By:
Counter-� ��
aigned
(Owner or his representative)
CerYiScate oi Completion
Date Approved: � ' �y By
Sanitarian
(OVER)
Location of well and sewage disposal facilities sketthed on back.
NOTE: Make sketch of installation showing lot size and shape, location of house,
supplies, etc. Note special problems existing on lot. Write in measurements in or er h�
at later date. Note location of water supplies on adjacent lots.
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e i anks, �r�vies, water
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PERSON COUNTY HEALTH bEPARTMENT
355A SOUTI� MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant I�� � ���0:,�
Address !'� � ����1S�r)r.+L County���'�vr�
Collected By ��j
Date Collected f�—t�7 �—�7 Time Collected �=�u
Source: �e7 Well ❑ Spring ❑ Other
Location: L� tlouse Tap pWell Tap � Other
�No Charge Charge
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� Results
Prese t Absent
Total Coliform � �
/
FecaVE. Col'i ❑ �
Reported B !O
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