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The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply ar�d Sewage Disposal
IMPROVEMENTS PER IT o.
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Owner: •
LocG�� . �. .
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p� Contractor J , �''�'`'
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Wa3e: Supplp: Prlvate �_ Public
Sewage Disposal Faailifies: No. bedrooms � Dishwesher, Dlsposal,
washing machine, other a tomatic appliances �
Slze of tank: Nitriflcation line: �� �3
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Other dlsposal faclllty:
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 and shall be main-
tained by owner in such a manner gs not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DIST,RICT HEALTH DEPARTMENT
STAFF BEFORE ANY POATION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved: —
Well:
Sewage Dtsposal:
By:
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Signe • � '�
Sanitari i
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Coun
oign ' � , 'i�11:
(Owner of� is representative) ;
Certiiicate oi Co�npleiion �\
�� �1,,, �,..,-�_._� ` g
Date Approved: ��'�a "�g BY�-��"_ �
Sanitaria
(OVEA)
Location � oi well and sewage disposal facilities sketched on back.
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. PERSON COUNTY HEALTH DEPARTMENT I��'�
325 SOUTH YIORGAN STREET
ROXBORO; YORTH CAROLINA 27573
I3ACTERII)l.O(;IC:�I, WATER.SAMPI:EANr11,Y.S'LS
N:�mc of Owner or Tenant
Address v L � J �
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connty
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Collected B�
Date Collected � � � — �� Time Collected
Source: Q�OVell ❑ Spring Q Othcr
Location: ❑ House Tap C�Vcll T:�p ❑ Other
LV�'Vo Charge ❑ Cha e
*�e� ��
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***************************�*********�*****************�*****x**��************
Totai Coliform
Fccal/E. Coli
Rc��ult.s
Present A.bsent
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❑ p�
Reported I3y ��.•� \��(.L� , I'rl I
l��ictrcport