OPDepartment
PERMIT # aeration Permit
New Installation )�K Septic Tank Nitrification Line Repair ❑ Expansion
PROPERTY LOCATION: � ca��� L� Q'6 c", 66S
Name: (owner) SUBDIVISION LOT # 15
System Installer: Q4t %!5 Registration #
Basement with plumbing: ❑ Garage 1 Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well ldQ) feet
System Type: `�j 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.
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 conditions, maintenance and reporting.
IV. Operation:
V. Other.
❑
D -Box ❑
Pump ❑ Alarm ❑
1-12O1-ine ❑ PWR Line
Following are the specifications
for the
sewage dispos system on the above captioned property.
Type of systtw�
Conventional
Other y cvf 70 Septic Tank: t O(D®
gallons Pump Tank: l D d 0 gallons
Subsurface
Drainage Field
o.
ditches
exact length width of
of each ditch feet ditches 3
depth of
feet ditches inches
French Drain Reauired:
��
Authorized State Agent :N �����\ k)� Date r. 130 1)
`" -13- �r-), 1 (-?