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The Distr�ct Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No
Date � 7 ?--�•.;
Owner: i� �+„ l! i n ys,.�tq� .
Location: ���� � � �
e.,.::a�+�r �I�T I�T�. — �= � ��b
Water Supplp: Private �— �blic
Sewage Disposal Faciliiie:: No. bedrooms Dishwasher� Disposal,
washing machine, o r suto tic appliances '��—
—f—��� ,✓+�i
Size of tank: Nitriflcation line: y, h_
Other disposal facility: �' :''"' �-�
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 INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT -
STAFF BEFORE ANY POATION OF THE INSTl�LLATIOIQ`,IS COV=
ERED AND PUT INTO USE. � 1 �` !�
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1�^ � �n �� � � � �k/`
:' � ;�l��"y ���� �' ;�{���! �
Date approved: Signedf ? —
Sanitarian
Wf:ll: ' ,.,,r� ,J
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Sewage DisposaL• Counter- t_,, '�
�.. cigne " -��/`�" � ;f ' . �
BY: (Owner or his representative)
Certificate of Completion
Date Approved: �� By: ,
Sanitarian
(OVEA)
Location o! well and sewage disposal facilities sketched on back.
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� �� A 1296
PERSON C UNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION Il�IPROVEMENT PERNIIT
Tax Map # �r�-3 Parcel # '—( �
Zoning Township (,' ' �C1,-�'Y1
Owner/Contractor J � T ; � te —�— 9 S,�
Location/Address ��-(,�e �`S j�_;1 �'(ZO� j� _�(� l-�� �,S C�G`. K
. -��ks� �- y (,�p . s.x.#
Subdivision Name Lot#
SEWAGE SYSTEM SPECIFICATIONS
�air (� Lot Area �, ��,L�(` Size of Tank �
) f Mobile Home ✓ Size of Pump Tank
iness # of Bedrooms_�_ Nitrification Line C
Max Depth Trenches
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is alt d or inte ed se changed.
Well and Sep ' Layout b �
Comments: � � /�lt ��_�CQ/YY�Q�.� �`�Q� `�'U
Installed by
����Z ) "`
Approved by.
WELL SYSTEM SPECIFICATIONS
Semi-Public
Date �' Installed by
Required Slab
Air Ven�t
�uir,�d 1We11
Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading infonnation contained in the application The environmental health specialist
is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading
statements provided to him in the application. Neither Petson County nor the environmental health specialist wazrants that the septic tank system will
continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\pennitsam O1/95 rev.1.0
ORIGINAL