A29 55 & 85The Districf I-�ealfh Deparfinenf
Orange, Person, Caswell, Chatham, Lee Couaties
SEPTIC TANK PERMIT
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Name of owner: .� • C' ��� �/ �l��-�f a � C
Name of contractor: �` � ��
Address and Directions ' �� )�
Q�'� � 1 `�� O' �I (,�'V �� (%✓
Person or firm doing installation:
Address � � "" ✓
v r ���
No. of persons to be serve� `
Additional appliances to be used: Disposal, dishwasher, washing
machine
Recommended: • Septic tank Gc�� o �1 �^.� f
�� �� S'�r ���i c� /3�'ic �— I �r.q �"0 � 1r S�
Nitrification line: ,� ? � �(n Q S `� �/ � � /
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecfed and
approved by a member of the Districi Hea13h Deparfinen! staff before
any portion of the installation is covered.
Date Approved: �" � 1 �L
Signe�
Sanitarian
By
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date.
SUGGESTED INSTALLATION (Date ) FINAL INSTALLATION (Date
(Road or Street) (�.oad or Street)