OPHTE# 13—"T-3'9r7 Ha,ett County Department of Publ`iL Health
PERMIT # Z:73 �`� " -O eration Permit /` 22693
I �' New Installation I " Septic Tank I if' Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:
Name: (owner) w �% SUBDIVISION d"t—. LOT #
System Installer: OVIm> Registration #
Basement with plumbing: ❑ Garage ❑ mber of Be ooms
Type of Water Supply: ❑ Community EZ Public Well Distance from well feet
System Type: p7,9 Types V and VI Systems expire in 5 years.
(In accordance with Table V a) Owner must contact Health Department 6 months prior to expiration for permit renewal.
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the
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AM
PERMIT CONDITIONS: ( � )
I. Performance: Systetrt shall rform i accordance with Rule .1961.
11. Monitoring: As required b Rule .l 61.
111. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
Permit and Construction Authorization.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewa disposal system on the above captioned propertyaij%j
Type of system: ❑ Convi 2 Other Septic Tank: 100 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches Z- of each ditch feet ditches _3 feet ditches ZY inches
French Drain Required: Linear feet
Authorized State Date ® - "� J