OPCounty ` of Public Health
PERMIT # "7�ic�— Operation Permit
New Installation Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: C0,5,,; ss/5 s>C
Name: (owner) SUBDIVISION LOT # c1Ml
System Installer: ; Qc,<44,4S Registration #
Basement with plumbing: ❑ Garage X, Number of Bedrooms L-i
Type of Water Supply:
El Public El Well Distance from well i n O feet
System Type: ° ) 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.
PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
11. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ NOX
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑
D -Box ❑
Pump ❑
Alarm ❑ H2O1-ine ❑ PWR Line
Following are the specifications for the sewage disposal
s stem on the above capttioned P�perty.
Q- I''-/
Type of system:
El Conventional X Other
��t> =?
Septic Tank: t000 gallons Pump Tank: gallons
Subsurface
No. of
exact length
width of depth of
Drainage Field
ditches L4
of each ditch 44:Da feet
ditches feet ditches i inches
French Drain Require Linear feet
Authorized State Agent ' Date
1H- 5- 3V� a--)