A27 158� i ��� f�'��
� 3 �� �
P�
�
�
The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Suppfy anld Sewage Disposal
IMPROVEMENTS PE IT No.
p Date� � ' � '�
Owner: �I,� �N� � A (� E Q�
Location: �� � � �� .� L-�� l �
RF � u�.Q C' ��E �E�
Contractor: �
Water Supplp: Private
E��E �����rn �
Sewage Disposal Facilities: No. bedrooms � Dishwasher, Sisgosal;
washing machine, other suto atic appliances L /
Size oi tank: ���1��,�� NitriBcation line• _�J �� i���
Other disposal iacility:
Water supply and sewage disposal facilities 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 INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY POftTION OF THE INSTALLATION IS COV-
ER A D PUT INTO USE.
f� � � —.� — �
Date approved: Signe �
Sanitarian
Well:
Sewage Disposal: Counter- . ��{��
BY. aigned �
(O � ner or his representative)
Cerliffcate o� Completion
Date Approved: �__�� By:
anitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
. �� J l
�
� i �
V..,�ti � � . . ;. •
� �
�II.IC'�
Building Additions/ Mobile Home Replacements
Tax Map #: �� 7 Pazcel#: �� g Address: 3`� � �eaV � r C-reek � kw ��
o�Cbora � C �7�7�
Approval Requested for: Mobile Home Replacement
✓�Building Addition
ApplicantName: � c��,�o,��, L. .��c'ar��er �r �
Address:
Phone #'s: 336 - q 7'-37 3
Permit Located: � s No
Installation Date: i�. 8 8G Design flow: (gpd)
Current Contract with Certified Operator on file (if required):
Water Supply: °� Well Public or Community
Wastewater system shows no visual evidence of failure on: g�� �� `� (date)
(Applicant's signature if site visit is not required) ,�.�s�.�
v
JV1 e�a � Cc`r o r� �� X� S �
�,., P► i- V11,1�.0. t Q�.-
Addition/Replacement Approved
Environmental ea Specialist
�f
Date
Np
Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573
Phone: 336-597-1790/ Fax: 336-597-7808 www.�ersoncount .y net