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The Distr;Gt Health Department
Orange, Person, Caswell, Chatham, Lee Counties
Water Supply and Sewage Disposal
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Owner: _ �.�, _���(�rt�'�!� -,- �'1
Location: ��—�4�X��'� • �����
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Contractor: ' `
Water Supply: Private � Public
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Sewage Disposal Facilities: ,. �s Dishwasher, Disposal,
washing machine, ot e autom tic appliances
� �� Nitrification line: �L43.r—
Size of tank: �
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Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Above recommendations based on information received and observed
soil condition. Septic tank and nitrification line MUST BE INSPECTED
AND APPROVED BY A MEMBER OF THE DISTRICT HEALTH DE-
PAR,TMENT STAFF before any portion of the installation is covered
and put into use. �
Date approved: .-? � � ��
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we'1: r, ,; ,r CERTIF �1T F--COMP ETI
Sewage� is sal• SignedS���q;�
/.?� � I( ; t - anitaria ��
By: , l % ! ' r i '`�"t� ,
The District Heaith Department
Countersigned
(OVER)
Location, of .well and sewage disposal facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at later date.
(1� (2)
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