OP: County Department1' Public Health
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PERMIT # ��?6�G Operation Permit
New Installation Septic Tank XNitrification line ❑ Repair ❑ Expansion
PROPERTY LOCATION: CSON (—'v
Name: (owner) o �-►on,E. v%-QG-Z5 SUBDIVISION gN,40 LOT # �-
System Installer: zS;,'- f LOS15 Registration #
Basement with plumbing: ❑ Garage "K Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 109 feet
System Type: 1 L 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.
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PERMIT CONDITIONS:
1. 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 ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional ) Other P_ 2- z.ow Septic Tank: 1000 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches 1 of each ditch feet ditches feet ditches inches
French Drain Require : Linear feet
Date
Authorized State Agent �^