A31 45The Districf Health Departmenf
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
DateT� `"' e� � �
Name of owner:
Name of contractor: �
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Address and Direction.ks �
Person or firm doing
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No. of persons to be served Bedrooms 1, 2, 3, 4.
Additional appliances to be � used: Disposal, dishwasher, washing
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machine
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Recommended• Septic ta � t'Y�
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Nitrification line: � �� �.—.-�
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 DisYrict Heaith Department siaff before
any portion of the installation is covered.
Date Approved: f�Q-�—'�,
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Countersigned
O. David Garvin, M.D., M.P.H.
District Health Officer
(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 INSTAIILATION (Date )
(Road or 6treet) (Road or Street) ,
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