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�The District Health Department
Orange, Pezson, Caswell, Chatham, Lee Coun2ies
Water Supply and� Sewage Disposal
IMIPROVHMENTS PERMI Nn._�:_ _
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Owner: — •
Location: � �
Contractor: � - �Q���� � S
Water Supplp: Private 1� Public
Faciliiies: No. bedrooms �— Dishwasher, Disposal,
wasl�i'i�g machine, other automatic appliances
Size of tank: �111_c�.���'� � � /
Nitrification line:
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-
PROVEB BY A MEMBER, OF THE DISTRICT HEALTH DEPAR.TMENT
STAFF BEFORE ANY PORTION OF THE. INST LLATION IS COV-
ERED ANB PUT INTO USE. � ,�
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Date approved: Signe ��% '
'" Sanitarian
Well:
Sewage Disposal:
By:.
Counter-
signed
(Owner or his representative)
Cerlificaie of Compleiion �
Date Approved: � By \
nitarian _
(OVEft)
Location of well and sewage disposal facilities sketched '�n back.
supplies, etc.
at later date.
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sketch of installation sho ' o s nd hape, location of house, � s�ptic tanks, privies, water°$ :�.:.� ��
fote special problems isting on'lot: Writ in easurements in order that installations may be located �
Jote loca tion of w er pplie a jacent ts. �
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