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PERMIT # Operation Permit
C~New Installation Septic Tank ❑ Repaic K Nitrification Line ❑ Expansion
PROPERTY LOCATION:
Name: (owner)~~ SUBDIVISION OD LOT #
System Installer. _ C:tN4t Registration #
Basement with plumbing: ❑ Garage ~jhlumber of Bedrooms
Type of Water Suppl : ❑ Community Public ❑ Well Distance rom well feet
System Type: -t t'- Types V and VI Systems expire in S years.
(In accordance with T ble V a) Owner must contact Health Department 6 months prior to expiration for permit renewal.
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1. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No
If yes, see attached sheet for additional operation c
IV. Operation:
V. Other.
maintenance and reporting.
Following are the specifications for the se age disposal system o"e above captioned property.
Type of system: ❑ Conventional Other lX CV_ ~ Septic Tank: gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of `
Drainage field ditches of each ditch- feet ditches feet ditches inches
French Drain Required: linear feet V '
Authorized State Agent
Date '
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Norm Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization
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