A41 45The District Health Department
CASWELL - CHATH,4M - LEE - PERSON COUNTIES
Wv t'er Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
.-� Date �� � - - �
Owner: � � ' ,•� < /1 ' " ��"�'_—
Location:
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Contractor: _ - �_�i�'
Water Supply: Private ;�-'"� Public
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Sewage Disposal Facilities: No. bedrooms -�
=washing machine, other autom fic appliances _
,Size of tank: �f �� t� ����� Nitrification line
Other disposal facility:
Dishwasher� Disposal,
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Water supply and - sewage, .disposal faci:ities lo�ation, 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 HEA�TH DEPARTMENT
STAFF BEFORE ANZ' PORTION OF THE INST� L TION IS COV-
ERED ANB PUT INTO USE. ,�
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Date approved: — Signe � � ���•=�: � � '{t�•
Well:
Sanitarian
Sewage Disposal:
By:
Counter-
signed
(Owner or his representative)
Certificate of Completion � /�
� /
Date Apprpved: ���1-� gy: � L�`✓�'�G�
�� S2 itarian
(OVER)
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
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