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OP RRDepartment 4M PERMIT # �+�-.v Operation Permit New Installation "'IR Septic Tank Nitrification Line ❑ Repair ❑ Expansion PROPERTY LOCATION: W `riG Name: (owner) �c ©.n �°r,cc�•�+ =1 v��.c�ES2�S SUBDIVISION Vr.rL. 5 LOT # System Installer: Registration # Basement with plumbing: ❑ Garage", Number of Bedrooms Type of Water Supply: ❑ Community X Public ❑ Well Distance from well t b d feet System Type: o. 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. ims system nas ueen mstaneu in compoance wim appucame Norm carmma aenerai xatutes, NO for sewage treatment and I b—i . and all conditions of the Improvement Permit and Construction Authorization. S'tA 691A#,v 0q- FUM11 LUNDIIIUNS: I. Performance: System shall perform in accordance with Rule .1961. 11. Monitoring: As required by Rule .1961. 111. 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 ❑ H2OLine ❑ Following are the specifications for the sewage disposal system on the abovfp,,�ccapti d property. Type of system: ❑ Conventional Other C.t�� G2 U�t Septic Tank: ln0(7)' gallons Pump Tank: Subsurface No. of exact length width of depth of Drainage Field -- -tfitclz _ of each ditch W-N 0 feet ditches feet ditches ^3y French Drain Requirek_ Linear feet Authorized State Agent ""*<� \� R6)-13 _ Date PWR Line gallons inches 13^ 5 -3u- 2oQq