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"` The Dis rict� I-�ealth Department
Oraage, Person, Caswell, Chatham, Lee Counties
�''' SEPTIC TANK PERMIT
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(� Nam of owner:
� Name of contractor: — ��r�'nq+�
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Ad�e�ss and Directions I� � rt' `�- -�.Td�C��_C ►
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Person or firm doing installation: � 1�. �� ���� �
Address �'� � � � �� �7 d �'[��� � 1
No. of persons to be served Bedrooms 1, 2,44.
Additional appliances to be used: Disposal, dishwasher, washing
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machine
Recommended: Septic ta 1
Nitrification line: �l J f %�� x�,
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Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecfed and
approved bp a member of the Disirici Health Department sfaif before
any portion of the installation is covered.
Date Approved: �—�(�—
By:
Signe�
Sanitarian
O. David Garvin, M.D., M.P.H.
District Health Officer
Countersigned
(Over)
NOTE: 1V�
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SUGGESTED
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sketch of installation showing location of house, septic tanks, privies, water supplies on
nt property, etc. Write in measurements in order that installations may be located at later
!��LATION (Date - ) . FINAL INSTALLATION (Date )
(Road or Street) �, {(Road or Stzeet) '
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