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The Distr�ict�Health� Department
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal
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Owner: • �
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Location• t�
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Waier Supply: Private —� `'— Public
Sew is osal Faciliiies: No. bedrooms _.,�'— Dishwasher, Disposal,
' machine ther automatic appliances
Size of tank: Nitrification line: — �
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PARTMENT STAFF before any portion of the installation is covered
and put into use. '' �
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Date
Well:.
BY..
Countersigned
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Location of well and sewage disposal facilities sketched on back.
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NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
suppiies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
�t later date.
(2)
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