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The District Health. Department
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Orange, Person, Caswell; Chatham, Lee' Coun2ies
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Water Supply and Sewage Disposol
IMPROVEMENTS PE T o.
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Owner:
Location:
Contractor:
Water Supply: Private Public ' �
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Sewage Disposal Facililies: No. bed�
washing machine, .pt,�iP�,rgu matic-
Size of tank: ` ���� �j'
line: �
, Disposai,
Other disposal facility: '
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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 as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTEI} AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION'�OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:
Well: t'
Sewage Dis�ps�
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By:
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Signe
anitari
�- Counter � ��
signec� �
wner or his representative)
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Certifica2e of Completion
Date Approved: ��B� �
Sa it ian
(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. Write in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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