OPCounty Department I
PERMIT # Operation Permit
New Installation Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: r—,;
Name: (owner) 0 ",' 0 �"j �*} C... SUBDIVISION LOT #QC)
System Installerr: ! ( - -\- � C Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms_
Type of Water Supply: ❑ Community Public ❑ Well Distance from well Zt7 feet
System Type: Z= 5 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 Vatutes, Rules for )ewage Ireatment and uisposal, and all conditions of the Improvement rermit and construction AUtnorization.
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PERMIT CONDITIONS:
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 ❑ N
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other.
❑ D -Box ❑
Following are the specifications for the
Type of system: ❑ Conventional
Subsurface o
Drainage Field ditches
French Drain Required: �\
Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
sew ge disposal ��sYystem on the above captioned property.
Other E_ �. "1 Septic Tank: C) gallons Pump Tank: gallons
exact length width of depth of
of each ditch Z feet ditches 3 feet ditches 0 inches
Authorized State Agent NN ��\ _�Aj Date d
ILA - 5-