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The_ Distrfzt__i�alth Department
I CASWELL - CHATHAM - LEE - PERSON COUNTIES �
�� Water Supply and �ewage Disposol
IMPROVEMENTS PERMIT No.
Date ! (5i - .� G' �"3
_Owner:__--- -- ! '� �'�— ,—� �� �� :
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- Location:— -
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Contractor: _ _ , ,�.��''�.-�;-� �
-Waler Supplp: Private ''� -�� Public
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Sewage Disposal Facilities: No. bedrooms �—, D'sh asherlI�is �al,
washing:machine, other sutomat'c appliance� �
Size of tank: ''�' �rNitriRcatiori line:
_. _. ..- -,.-; E_C'�. _��11-31�»Vdlve
Other disposal facility: —
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Water supply and sewage disposal facilities location, instal ation 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-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTAL�.ATION IS COV-
ERED AND PUT INTO USE. < � � � `•�. : -
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Date ,approved
Well: `
Sewage Disposal:
By:
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Counter- �
, ����...._.,,,�,�
aigne
(Owner or his representative)
Certiticate of Compleiion ' �
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Date Approved: ..,I� By _ `
� itarian
� (OVER) -
Location of well and sewage disposal facilities sketched on back.
NOTE: Make
supplies, etc. '
�t later dACe.
.
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of installation showing lot size and shape, location of house, septic tanks, privies, water
cial problems existing on lot. Wrlt�e in measurements in order that installations may.be located
:ation of 7u er supplies�on a'acent lots.
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