A31 95!
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i'he �isfr�cf ealfh Deparfinent
Osange, Person, Caswell, Chaiham, Lee Counties
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SEPTIC TANK PERMIT
` � Date �' � v Y�
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Name .of o�er:
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Name of contractor:
Address and Directions ��� �' u����—LI1i �� S
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Person or firm doing installation: –
Address
No. of persons to be serve� Bedrooms 1, 2, 3C%4.
Additional appliances to be used: Disposal, dishwasher, washing
machine N d �,, P�'
Recommended• Septic tan1� �/� r
� � i1 } � ���c � ` l.�e�• i�' ci = �t' /
Nitrification line: �
4 w, y_i -tz
Above recommendation based. on information received an observe���
soil condition. Septic tank and nitrification line must be inspected ande-,,
approved 8y a member of ihe Disfrict Healfh Deparfinent sf b f r��
any portion of the installation is covered. %
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Date Approved: � �-�-�jj
By:
Signed
Sanitarian
O. David Garvin, M.D., M.P.ii.
District Health Officer
Countersigned
(Over)
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�.'jNOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on-
�'"' ��W adjacent property, etc. Write in measurements in order that installations may be located at later
� �''" date. , ; - \ �,,
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SUGGESTED INSTALLATION (Date ' ) FINAL INSTALLATION (Date ' )
(Road or Street) . (Road p� treet) :
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant ��%►�L I�a�ne�a
Address �(g5 .�n�(i�, Lan��� County erso
Collected By �S _
Datp Gollected �1� 5�►G Tirne Collected 1Z:30
Source: �IVell ❑ Spring ❑ Other
Location: C�louse Tap ❑ Well Tap ❑ Other
❑ No Charge �harge
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Total Coliform
Fecal/E. Coli
Results
Present
❑
Reported �
Date Reported % " � � ��
Report Called ��ES ❑ NO
Called To ''f�f�'1�1.u. �Q� �- lv • 1ln
Absent
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