A41 16��
The Disfr�ct Health Deparfinen�
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC 7'AI�lIC PER�A1�'
Date !�? "' , � •� (�'�!
Name of owner: ,LY��' -�'� � 6P�J'"�— �. L�"-iE'i Z'_�
Name of contractor: �• ���I7 �'- 1� � i''L�-S ,
Address and Directions .�� � � !� `�'� • ���4
u, i� n.1 � .� _ y�
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Person or firm doing installation: � ��
Address `U
No. of persons to be erve� Bedrooms 1, 2,' , 4.
Additional appliances to be used: Disposal, dishwasher, washin
machine
Recommended• , Septic ta �'� ��/ �
Nitrification line:
f �, l� / --
Above recommendation based on information received , and observed
soil condition. Septic tank and nitrification line must be inspecfed and
approved by a member of ihe Disirict Health Department s3aff before
any portion of the installation is covered. '
Date Approved: �j -� /� '
By:
Signe�
Sanitarian
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 on
adjacent prop� rty, etc. Write in measurements in order that installations may be located at later
date. {[i
SUGGESTED INSTALLATIQjd (Date ) FINAL INSTALLATION (Date )
(RDad or Street) (Road or Street)
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