A28 60s
The District Health DepArtment
�� CASWELL - CHATHAM - LEE - PERSON COUNTIES
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Water Supply and Sewage Disposal
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Owner: _
Location: .
Contractor: --�
Water Supplp: Private
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Public
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Sewage Disposal Faciliiies: No. bedrooms �� Dishwasher,
washing machine, oth auto��tic appliances
Size of tank: �� '�'f � Nitrification line:
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�ther 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 an�3 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 II�S'i'ALLATION IS COV-
ERED AND PUT INTO USE. tl / ; i j� �tf J
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Date approved: Signed ''• ��17�'�� '• f �� ����
`�l `'�Sanitarian � ` T
Well:
Sewage Disposal:
By:,
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Counter � �r;
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signed 4. J It; .,�
(Owner or hisrr�` presentative) '.
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�ertificate of Complelion
Date Approved: ���s�� BY
,� tarian
(OVER)
Location of well and sewage disposal facilities sketched on bac:c.
NOT�,�e sketch of installation showing lot si � shape, location of house, septic tank�ivies, water
supplies, e c. Note special problems existing on lot. n measurements in order that installation ay be located
at later date. Note location of water supplies on adjacent lots.
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Tax Map #� Parcel #
Existing Sewage System Report For:
Mobile Home Replacement
✓ Addition Type: ��'1''C,eilP �(� B !� � „ .
f - eSC,'Sfi�"�--0 0/1 � ���i�
? IQ �-�}-. Home Phone#
Original Permit Located: l� Water Supply: �i\I�—
Septic System Designed For: �/�ential Business Other
# Bedrooms ✓ # Employees Other
System Type: �� vPl'Y�� �Q .! Tank Size: d Nitrification Line: �� �X 3'
Date Installed: ��'�%-�� - Certified Operator Required: N�s4
On-site wastewater disposal system shows no visual signs of malfunction on �-'��"C3Z .
Environmental Health Specialist Date: � D-QZ