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The District Health Department
Ozange,..Aerson., Caswell, Chalham, Lee Counties
...
'� Water Supply and Sewage D(�' p�o �
IMPROVEMENTS PER T ,.No. �' �' �
� Date �"'. 1��
� F�d>' �-3 �t d���t_i''� .t�
� Owner: '�•�,
'r: t'^.. c 1" -�-'s� r" ;� f- �
a pq Location: '4"'"%� . ' `
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Q, Contractor• � �—
�.
� Water/tSpPPIy: Pri/yate- f=s,,.c"" Pu/bli(�
PY/.tit'..i�sr..� LrUi�..d'#ifQ .fi i��✓�'I�-' .F !
Size of 'tank: .—
�, — ';-3rj: ,�}�.,y, "t �-�_t f .�„ ,. � '_"r-�.°+.
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�es: No. bedrooms � Dishwasher, isposal,
� automatic appliances , 't Qn
��
`` � 7 i ' �
'`� Nitrification line: =�'� � ' � �
-�� ?+�.� � X 3'' � �vrJ ����✓�
Other disposal facility: �Q� .3��'92 ��
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-
PROVEI? BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT --
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ER�D AND PUT INTO US�.
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Date approved: '� .,".� Signed—.�.--'��---.----`r . •< ^•j;,,,..
�' � Sanitarian � i)
Well: tl �,�
�
Sewage ' os�» t �� Counter-
B�: =/%* �•' , signed
(Owner or his representative)
Certificate of Completion �
Date Approved: � � By: � � ' �. '_
S arian
(OVER)
Location of well ;and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of ho�e, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measureme ��in orc�,e�,hat ynstallations may be located
at later date. Note location of water supplies on adjacent lots. ti n�
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