A27 108G
The District Health Department
Orange, Person, Caswell, Chalham, Lee Counties
Water Supply and Sewage Disposal`
��PROVEMENTS PER IT No.
Dat '
Owner: i��i��l �� V� � urr� tjiL;��
Location:
3; f.r . / : ; .
1 .^>Y-l:'/ Co `�
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Contractor: ' -' ' �
Wale • Suppl�r: Pr'vat � ' Publf�c��
�� � d '- — �, c���-
/ t_------ ----
Sewa e Dis sa�acili2ies: No. bedtooms �_ �ishwasher, Disposal,
�shing mac ine� other autom ic appliances ��—T
Size of tank: �� ^ �'' ` Nitrification line: '
� ; '. . � �. _... ntF
Other disposal facility:
- �r��� �_1_
Water supply and sewage disposal acilities 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 INSPECfiED AND AP-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPAR,TMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE. � �
r����?/t "L ���`
1/� jn� ���zit(;.f�.
Date approved: _ `� C�–'�� Signe� "�•�� �
�/� � Sanitarian
Well:
�
Se ge Disposal; Counter-
' _�; _- gy ���� � / signed
(Owner or his representative�
Cerlificafe of Completion ~
�
,( !�
Date Approved:/���"-�/�Y: "
' 'tarian
(OVE
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
�.t supplies, etc. Note special problems existing An lot. Wr.ite in measurements in order that installations may be located
at later date. Note location of water supplies on adjacent lots.
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