OPHTE #A - ~- Tsai a ..at County Department of Public dealth 18909
PERMIT # /q-Tvt, Operation Permit
Per it
2/New Installation � c Tank El Repair R/ Nitrification itrifcation Line ❑ Expansion
PROPERTY LO(ATION:.s2 /763
Name: (owner)AW 1511Ai/ T0A'A 'l'>J SUBDIVISION G*ZL92r1' 61,o#s LOT #
System Installer: &yr •s Registration #
Basement with plumbing: ❑ Garage umber of Bedrooms `l Blw—
Type of Water Supply: El Community Vpublic ❑ Well Distance from well feet
System Type: ZS°ln%Uz Tta�J %�— T,,o, If C,— 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 Improvement Permit and Construction Authorization
rtKMII WNUMURY
I. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
V. Other.
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tits
N
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System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
Following are the specifications for the sews g disposal system on the above captioned property.
Type of system: ❑ Conventional Other 25'0/o)4 qh :lAJ�� EZZA,fSize of tank: Septic Tank: — gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 166 feet ditches 3 feet ditches 11-71 Z- inches
French Drain Required: Linear feet
Authorized State c i
Date /2 —ZI -X
A
II
1-1 1
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