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he Disfricf Heolfh Depar#menf
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PER1dlIT
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NameTif owner:
Name of contractor: -� � �� 1�
Address and Directions R�,�f��►t, o, b a±'° ,�_C j
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Person or firm doing installation:
Address
No. of persons to be serve� Bedrooms 1, 2,�4. ,
Additional appliances to be used: Disposal, dishwasher, washing
machine .�� �'S' ►'► C�
Recommended• Septic tank � d n�� I,
/
Nitrification line: f��%� e� �� � I�
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and
approved by a member of the Disfrict Heallh Department staff before
any portion. of the installation is covered.
Date Approved: �r- 3 � - �-
By:
Countersigned
Signe�
Sanitarian
O. David Garvin, NI.D., M.P.H.
District Health Officer
(Over)
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NOTE: Make sketch of installation showing locaiion of house, septic tanks, privies,.waier supplies on .��;{�`'�'
4 adjacent property, etc. Write in measurements in order that installations may be located at lat �,�
, �, .
•� _ date. � � ��
�;SUGGE5TED INSTALLATION (Date ), FINAL INSTAId.ATION (Date -''� )
�; (Road or Street) �� i� F�t , � , , +x,� / (Road or Street)�^��,�''
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PERSON COUN`I�Y HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IlVIPROVEMENT PERMIT
Tax Map #�� Parcel #��Z _
Zoning Township
Owner/Contractor 2� Date � I� —
Location/Address 12 , ,U��, __ _ 1'�11, � ��, - --
s.x.# 11�2
Subdivision Name Lot# /(Q
I SEWAGE SYSTEM SPECIFICATIONS �
SFD
Lot Area_
Mobile Ho
# of Bedre
Size of Tank
i Pump Tank�
i ' ation Line
Max epth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or intended use changed.
Well and Septic Layout by
Comments:
Date
Installed by,
Approved by
WELL SYSTEM SPECIFICATIONS
Individual�_S emi-Public
Public Replacement
Site Approved �
Well Head Approved
Grouting Approved �'a/a
"nmmPntc• �Pr�'%i /D7 �/7�� �m� �/1�
Date
by
Required Slab
Air Vent
Required Well La� �
Well Tag
%
Approved by
This report is based in pazt on information provided the homeowner or hisJher representative in the application submitted for this pettnit The
envitonmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the application. Neither Pe�on County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactority in the future or that the water supply will remain potable. c�amipro�permit.sam O1/95 rev.1.0
ORIGINAL
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