A40 90The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
I ROVEMENTS PERMIT
Dat -� `
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Owner:
Location:
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Contractor:
Water Supplp: Private � ��ublic
Sewage Disposal Faciliiies: No. bedrooms —� Dishwasher, Disposal,
was " g machi other automatic appliances "
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Size of tank: ���v Nitrification line:
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-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INS�'ALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well:
Sewage Disposal:.
By:
Signed '
Sanitari
Counter-
(Owner or his representative)
Certificate of Completion
Date Approved:��.���� B .
rian
(OV
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. Writ i e surements in order that installations may be located
at later date. Note ocation of water supplies on adjace t�.
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