A40 58-
The Disfrict Healfh Departmenf
Orange, Persoa, Caswell, Chatham, Lee Couaties
`SEPTIC TANK PERMIT'
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Date� � �
Name of owner: � �� �-� �— I � �'��
Name of contractor: �
Address and Directions '�-' .�;
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Person or firm doing installation:
Address C O I'Y� 1'iJ ;
No. of persons to be serve� a"''"^^"^�-',=', �; "—
Additional appliances to be used: Disposal, dishwasher, washing
machine � �� �
Recommended
Septic tank `�� � �� ��
Nitrification line: J�' � I X �'
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspected and _
approved by a member of the District Health Department staff before
any portion of the installation is covered.
Date Approved: , ` I� �'
Signed
Sanitarian
By:
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
_
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies
adjacent property, etc.� Write�n measurements in order that installations may be located at late.
date. �{} y �,�,,�-g
SUGGESTED INSTALLATION (Date ��� ) FINAL INSTAId.ATION (Date )
(Road Ol' Stleet) � �� (Road or Street) ,
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