OPDepartment Public
New Installation Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:
Name: (owner) C\-% *5'� s0ta SUBDIVISION - LOT # f`N
System Installer: >s S�T `cwt Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms _3
Type of Water Supply: ❑ Community Public ❑ Well Distance from well ► ® feet
System Type: a, 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
�i0`V7C—
FERrul
/ 1
LunuuwnY
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
❑ Pump ❑
Alarm ❑
Following are the specifications
for
the sewage disposal system on the above captioned property.
Type of system: ❑
Conventional
Other "PL-Qy,1
Septic Tank: 100 4
Subsurface
#o. of
exact length
width of
Drainage Field
ditches
of each ditch ® feet
ditches 3
French Drain Required:
ar feet
Authorized State Agent \ �''.Date t
H2OLine ❑ PWR Line
gallons Pump Tank: gallons
depth of
feet ditches 20-3(5 inches
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