OPHTE# ��- -�3�`� as ;tt County Department of Publi, Jealth 23394
PERMIT # �� `�� t 0 eration Permit
New Installation X Septic Tank) Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: nor
Name: ( owner) SUBDIVISION LOT #
System Installer: Registration #
Basement with plumbing: ❑ Garage )5ir Number of Bedrooms t�
Type of Water Supply: ❑ Community Public ❑ Well Distance from well S 00 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.
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
133
J I
ro
G
C
A 0 6- f50
s
c
n
p .
0
V
C
FILM] LUNDIIIUN):
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 opera on conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D -Box ❑ Pump ❑ Alarm ❑ 1-12OI.ine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of_s stem: ❑ Conventional Other F2, 'Ft_ay./ Septic Tank: 100 o gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditc e of each ditch feet ditches _ feet ditches inches
French Drain Reouired:,N, "wear feet
Authorized State APent �� ����� �. » Date "!
� �-i � 5�-- 33�i 1`�