P203 Hwy 801NAqR
DAYIE COUNTY HEALTH DEPARTMENT
(Septic Tank) Improvem nts Permit and Certificate of Completion _
(Ground Absorption Sewage Disposa� System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR DATE - :'^ PERMIT
NQ:.., .
LOCATION 203
1 S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE MOBILE HOME BUSINESS ❑
Ho se Trailer 8 al. 40 Sq. Ft.
NO. BEDROOMS NO. BATHROOMS ;,... '"""°"'`"`"" "`"
_Two droomHouse 8 6 F
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 1900 Gal. 260 ,Sq. Ft.
AUTO. WASH. MACHINE YES ❑, ,NO ❑ R
SITE SUITABLE YES ❑ <'NO ❑
SIZE OF TANK' gal.
NITRIFICATION FIELD L sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual Public- ❑
IMPROVEMENTS PERMIT BYIt / 1'. yy INSTALLED BY
CERTIFICATE OF COMPLETION B, A_ % Date 7 %/C' -7-L
(8/16/73) *Construction must col4iy with all other applicable State and local regulations
LOT AREA �df J
15r 3,4
,N. C. State Board of Health, Laboratory Division, Raleigh,; N. C.
Certified Request For A Free Water Analysis
Name Of Owneror Tenant:_00 Lk!�j C4 S K(ZI Ie15.1
44 County: AN2' �-
Source: Well Q.Y Spring O Other:
Depth • ft. Pump:and Operated O Power Driven 94—
Collected By �u 1""0-30 Date �' �� Time �3J
(Mail Sample Immediately After Collection)
Signed r Y.,u„-J'(3
D �U S
Unil+E9!!""4A!Drer
1
Sanitarian)
Address
ti
270;P -R'
ZIP CODE. _
,Do Not.Write Below This Line
+Bacteriologic Analysis
Physical Analysis '
:.i
Sediment
LB COLIFORM
BOB
,
Odor,
1 j �
1
Color
2 Not Found 2
3
3.
Turbidity.
Present
Appearance
4
4
5 MPN
5
Key: V = Very, SI = Slight, Mod = Moderate
Received
,, ,
Re g1c,
Ud..
Y'
;SBH Form 1294
�3
LABORATORY
r_
Reported
By
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