OPHTE# ,3 -� sz��� Hari—a County Department of Public ,wealth 23474
PERMIT # p eration Per
New Installation Tank ��Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION -v3-7
Name: (owner) 17030 SUBDIVISION LOT # t 60
System Installer: t gcO- Registration #
Basement with plumbing: ❑ Garage umber of Bedrooms 3
Type of Water Supply: ❑ Community Cr] Public ❑ Well Distance from well feet
System Type: o 412% Q&0 - , Tti 227,-3 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.
wz;t -- -Y
uos system nas oeen mstaneo in compuance wim appucaole norm Laronna uenerat statutes, Rules for )ewage treatment and Disposal, and all conditions of the
rtnrill t.UIVUIIIUNY
I. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
V. Other:
0
7
3b
ina
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
c'
Permit and Construction Authorization.
r-
L.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewa-ge disposal system on the above captioned property.
Type of system: ❑ Conventional 1?f Other 59oa Septic Tank: 1000 gallons Pump Tank: / °a 6 gallons
Subsurface No. of exact lengt width of depth of
Drainage Field ditches 3 of each ditch o6 feet ditches feet ditches inches
French Drain Required: _ linear feet
Authorized State Agenf—..._. x--- i'"/ Date 10 - 01 - t