A24 83The District Health Department
CASWELL - CHATHAM -�LEE - PERSON COUNT�ES
Water Supply and Sewage Disposal
: �PROVEMENTS PERMIT Nq f
Date `'� -�— �
r''�V'! / � /' �
Owner: ,
• Location: �'
} i.� , ;_C � _� _. .;>
,���'fi. `�t-
� = ;' ' , p, Contractor: �� � �- �a�.�• �
� Water Supplp: Private !� �, Public
1 R I , � , -
4 . 1 `.
�
�� ! �i �t� ... � .:'1..�)'
i
Sewage Disposal Facililies: No. bedrooms Dishwasher,
washing machine, otheT sutomanic appliances —��
Size o� tank: ' �'t!���J''� NitriBcation e: �'.�-��
� � �: 1��.{'� / �� r %"l .
)isposal, �
,
�. -T
!1 ��
f, � �-' i: �,:-v�`c'
� �- • _
,�
Other disposal facility: ��� '" �'"�-�- � �/�` �' � �"y�� � �' � i�'�
� � � r,s....�. ,
` � ;I
Water supply sad sewage disposal facilities location, installation and
protection must meet state and local regulations. ,� � . --.1
Septic tank should be pumped out every 3 to 5 years an.. �hall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE IN�SPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DFPARTMENT
STAFF BEFORE ANY POATION OF THE I�iS7.'AI:LATION IS COV-
ERED AND PUT INTO USE. � �'' '
r `/, I ±` � � � ^:
� . � ,[ )! � I ,
� '� / if �'� / ��1 .
; l !:��i��! � :3,����.,,�, :,..
Date approved:
Well:
Sewage Disposal:
By:
r� f; �--�: _ _ ,
Counter-�� %' � � � , /i
signed � . f.; :1�I���c4Z.�'
(Owner or his representative)
Certifieate of Coaipletion
/� (� � �
Date Approved: � � � BY:
n arian
(OVER)
Location of well and sewage disposal facilities sketched on back.
NOT"'.e�.-M ke sketch of installation showing lot size --��hape, location of house, septic tanks, es, water
supplies,� Note special problems existing on lot. Wrate in measurements in order that installations may be located
at later date. Note location f water supplies on adjacent lots.
!
f11 , i Un; r��