OPAarnett County Department of Public Health 2344-5
PERMIT # 0281 63 Operation Permit
ErNew Installation 2*'�Septic Tank C�Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 0a 2.r eJ
Name: (owner) /11C k/e,-c 4- A-- <,r SUBDIVISION '�c�.V, vLa LOT # 131
System Installer: F d -r c GO-KACr Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms 6—
Type of Water Supply: ❑ Community Public ❑ Well Distance from well feet
System Type: 1v-- h 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.
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 operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D -Box ❑ Pump ❑ Alarm ❑ H2O1.ine ❑ PWR Line
Following are the specifications for the sew dispo system on the above captioned// proper�Y.
Type of system. Conventional Other ru, -it" Qv- t �y dc,— hls- Septic Tank: S�O gallons Pump Tank: 260 gallons
Subsurface N0. exact length f width of depth of
Drainage Field ditches of each ditch `f ,7 0 feet ditches feet ditches inches
French Drain Required: N' l inear feet
Authorized State Agent Date
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