A33 43�
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The District Health Department }
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposol
� IMPROVEMENTS PER IT • .�_
t,-- - Dat ���1�—
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Owner: ' �L:'''� %��
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Location:
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Contractor: .
Water Supplp:� ivate Public .
Sewage Disposal Faciliiies:
washing machine, �
Size of tank:
Other disposal facility:
Dishwasher, Disposal,
: appliances /
Nitrification line: `
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 INSPECTEIl AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
We1L•
Sewage Disposal:
By:
Certificate of Comp ti n 7
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Date Approved: � �� By: � �
itar a '
(OVER)
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
supplies, etc. Note special problems existing on lot. Write in measurements in order that installatioris may be located
at later date. Note location of water supplies on adjacent lots.