A32 118The Distr+et Health� Department
Orange, Person, Caswell, Chaiham, Lee . Counties
Water:Supply and Sewage Disposal - -
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Owner: 4 � `
Location: � �
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Contractor: � � r ,
Water Supplp: Pri `�te ' �--'"��
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Sewage Disposal Facililies:wFT�rr= ed�r•t� Dishwasher, Disposal,
washing machine, other. auto atic appliances
Size of tank • +��� ��°A� �?j'�� • Nitrification line: �� t�� �
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Other disposal facility:
Water supply and sewage disposal facili{ies location, ins4allation and '
protection must meet state and local regulations.
Above recommendations based on information received and observed
coil condition. Septic tank and nitrification line MLTST BE INSPECTED
A1V� A�PR6V�D BY A MEMBER OF THE DISTRICT HEALTH DE-
PAR.TMENT STAFF before any portion of the installation is covered
and put into use. ,
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Date appro�ea: ERTIFICA E�OF. . COMPLET{4�;
Well: � � �%�' . , �
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Sewag osal: ;
BY � �� '��F��IHealth Department _ ;
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Location of well and sewage disposal facilities sketched on back.
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