OPHTE# t4 -5 arnett County Department of Public Health 23284
PERMIT # �� Operation Permit
New Installation X Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATIO :N-1—i,a GE o
Name: (owner) i L.a� �2� q �C—aS SUBDIVISION y n tsi LOT # 5 3
System Installer: Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms L3
Type of Water Supply: ❑ Communi Public ❑ Well Distance from well ®d feet
System Type: --U 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
rt1SP111 LUN1,111IUN):
I. 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 cc
IV. Operation:
V. Other:
maintenance and reporting.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above aptioned operty.
Type of system: ❑ Conventional ` Other C Septic Tank: 1 6®'�) gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field of each ditch feet ditches 3 feet ditches 117J"20 inches
French Drain Required: feet w Gvn (W 5
Authorized State Agent 5 Date Gila.
tI-} -5- ��