A35 12AThe District 1-I�alth Deparfinen�
Orange, Person, Caswell, Chatham, Lee Coua3ies
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� SEPTIC TANK PERMIT
� � �
� Date
� Name of owner: ��-{ �'� LL� �`' (�'��S
Name of contractor: p� r1�r] 1+��hTr �
Address and Directions - C- �
�n ', `� Ll! LI � V•� '� 1�-� o�-� 1�� �
Person or firm doing installation: � e+ C{
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Address
No. of persons to be serve Bedrooms 1, 2,�4.
Additional appliances to be used: Disposal, dishwasher, washing
machine � 0 n �
Recommended: ,� Septic tank �� Q� �� I 1
Nitrification line: � � - ( • �i�� .
Above recommendation based on information received and observed
soil condition. Sentic tank and nitrification line must be inspected and
approved by a member of the District Healih Department staff before
any portion of the installation is covered.
Date Approved: q— y�J " 7'�
Signed
� Sanitarian
By. �
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
�TOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
�� adjacent property, etc. Write.in measurements in order that installations may be located at later
�.�. date.
SUGGESTED INSTALLATION (Date ) .FINAL INSTAIILATION (Date )
(Road or Street) p-, (R,oad or Street) r"
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