A40 83The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERM IT No.
i _'7 ��-
/i fJ , �ate�—�- �
Owner: ` �',,:.�F �i ,...c.;^ ._ ;�-
Location• : � ` ' � •f='t''r !' ,��%,r° ^..�' ,�µ [�-�;7e-
� � -t= : �Ir ✓ �
Contractor:
Water S��ply: Private '� �bl�
�t-. � , r` C
; �� Ei.t � � ' - r � � f� i� +
� c=T� i
Sewage Dispo�al Facilities: No. bedrooms � Dishwasher, Disposal,
ashin� e, o�r automatic appliances
Size of tank: r' `� '� Nitrification line: ���'� ��-�—T_
Other disposal facility:
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 an3 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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved: _
Well:
Sewage Disposal:
By:
Certificaie of Completion
Date Approved: �'�l -'
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Signe �`l . , � �;, i.
anita�an !
Counter-
signed ,
(Owner or his representative)
(�
\
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a 'taria
(OVE
Location of well and sewage disposal facilities sketched on back.
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. Wrste in measurements in order that installations may be located
at later date. Note location of water supplies on �adjacent lots.
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