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The Distric� i�ea�th Deparfinenf
� Orange, Persoa, Caswell, Chatham, Lee Counties
SEPTIC TANK PERMIT
DatPT � � ��
y,�,�r
Name of owner• �a.�� d�i'i �? � �/i�' c'1� C� �:'�' �f_�
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Name of contractor: � �,,,��
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Address and Directions �" (__ �
� � A ��r, _. ti5 !i��' �r�u 1�1��1f '� � � � ,'D �+aD�`cr%
Person or firm doing installation: s 1•� P�� j�/. .[;%i(�f �,_
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Address � "'�� I �. C3 ��"��1. r�.. ,i
No. of persons to be serve�7 Bedrooms 1, 2;( 4.
Additional appliances to be used: Disposal, dishwasher, washing
machine ��.�'L� 1 '�
:� Recommended: Septic tank
Nitrification line:
Above recommendation based on information received and observed
soil condition. Septic tank and nitrification line must be inspecied and
approved by a member of 3he Dislrict Health Depaztment staff before
any portion of the installation is covered.
Date Approved: ��- �� � � d� �
By:
Countersigned
Signe�
Sanitarian
O. David Gazvin, M.D., M.P.H.
District Health Officer
(Over)
PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD
ROXBORO, NORTH CAROLINA 27573 -
BACTERIOLIOGICAL WATER SAMPLE ANALYSIS
Name of Owner or Tenant �R►V�U W�*�S'cEX�n
Address 1�� �a� ��G '�x7 County ��
Collected By �• SMI�
Date Collected �' a`� -1�5 Time Collected 1� : 55 ��
Source: 1�We11 ❑ Spring o Other
Location: �House Tap ❑ Well Tap ❑ Other
❑ No Charge '� Charge
..............................................................................�
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Results
Present Absent
Total Coliform ❑ �
Fecal/E. Coli ❑ �
Reported By � �
�
Date Reported � �a S-1 S
Report Calied ❑ YES �O
Called To