A25 31AThe District 1-lealth Deparfinenf �
Orange, Person, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
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Name of owner: �" S
Name of contractor:
Address and Directions /; � ,�1�� ��cLS�
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Person or firm doing installation: ✓� �' �,
Address ��" ���'��
No. of persons to be served Bedrooms 1, 2� 4.
Additional appliances to be used: Disposal, dishwasher, w�
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Recommended: Septic tank 1Q� 4�+/ �
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Nitrification line: �jt�� ���rkErl��t sc� X�'
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line mus! be inspecfed and
approved by a member of ihe Districi Health Department staff before
any portion of the installation is covered.
Date Approved: r� 3/`%.�
Signe�
/`") Sanitarian
B - .d� �
O. David Gazvin, M.D., M.P.H.
District Health Officer' '
Countersigned • • -
(Over)
NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on
adjacent property, etc. Write in measurements in order that installations may be located at later
date. '
SUGGESTED INSTALLATION (Date )
(Road or Street) .
FINAL INSTALLATION (Date )
(F.oad or &treet)
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