A30 77The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
�r Supply and Sewage Disposal
IMPROVEMENTS PERMIT o.
Date — —
Owner: ✓�[�. G 1��'v� ���a}
Location:
�— /1�.�—.
�
Contractor: ! �� � f
Waler Supplp: P�rivate —�� Public
Sewage Disposal Facilities: No. bedrooms Dishwasher, Disposal,
. .,rr-.........�
Nitriflcation line: �a x3�
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 and 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 DEPAFtTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:
By:
Certificata of Completion
Date Approved: ' �!'"
�
, � .IEf �, 1 %
- . - � .
Counter-
aigned
(Owner or his representative)
�' �� � ✓ti��� �.,
By: � � ' ��
S itarian �../
(OVER) '
Location of well and sewage disposal facilities sketched on back.
� Person County Health Department
Sewa e System Improvements Permit
Date: - ' Permit Void After �Y�
Owner: .s�t.c.l__ � . _ _ �'l�;�,bk:�.c,�T SR# �..�, �4
Subdivision Name: Lot #
Lot Size: ��r.,.�. Type of Dwelling:
Water Supply: Private: �� Public:
Semi Private: If not Private Tax Map# ' �
Parcel .# of Water Supply or Name of
Supplier# C
Bedrooms: Garbage Disposal --- ��,,.�„Q,Q � f
Basement � Basement Fixtures --- - �
INFOR TIOI�I CERTTFIEI,� B -
Sanitarian: ��J er or representative
REPAIR: �ALUATION: �
-------------------------- �
Size of Septic Tank: �d gallons . �
Nitrification Line: � �
Depth of Stone: 12 inches
Max Depth of Trenches:
OPERATIONAL PERMIT• yes no�_ �
Remarks: _ ,.t�— �
iv�c9 c�.� �.t'.c�.. J[.i� iL.� ,� i�[".i' .�.t L�J
--------- � ---------------
Da Well Approved: � Well should be 100 ft. &om any sewer system
BY Sanitarian c�
Da waga stem A rov . / 0�,� �"� 1
BY Sanitarian ,.,,j
CER CATE OF COMPLETION �
Contrac �
------------------------ a�
— rv
Sewage System location, installation, and protection must meet state and local; �
reguladons. Septic tanlc should be pumped out every 3, to 5 years and shall be i
maintained by owner in such manner as not to create a public health hazard.
Septic tank and nitrification line must be inspected and approved by a member of
the Person County Health DeparUnen[ before any portion of the installation is
covered and put into use. O
Location of sewage disposal sewage system sketched on back '
�
(OVER) �
�, 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
� at later date. Note location of water supplies on adjacent lots. ' .
� (1) � (2)
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