A27 39The District Health Department
CASWELL - CHATHAM - LEE - PERSON COUNTIES
Water Supply and Sewage Disposal
IMPROVEMENTS PERMIT No.
�I I�j6U'N Dat,e Q-.? E�' T—'—
Owner: � ' �� �'
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Location: '�
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Contractor:
Waier Supply: ivate �{,� Public
Sew�a.g�e _Disposal Facilifies:
,w ashin machine other a�
Size of tank: r�.� Q�
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Other disposal facility:
bedrooms "S Dishwasher, Disposal,
atic appliances —
�� Nitrification line:
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 an� 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-
PROVEB BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
Date approved:—
Well:
Sewage Disposal:
By:
Certiticate of Completion
Date Approved: �L=,��BY
(OVl
Location of well and sewage disposal facilities sketched on back.
Signed
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Sanitarian
Counter-
signed
(Owner or his representative)
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. Note location of water supplies on adjacent lots.
(1)
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(2)