OPDepartment of Public Health 23638
PERMIT Operation Permit
New Installation X Septic Tank>< Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:
Name: (owner) `�� y-"AL41 t + r2F, SUBDIVISION M EA.255N C -n 1 LOT # -5
System Installer: I �_- Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms '+
Type of Water Supply: ❑ Community >� Public ❑ Well Distance from well t:DQ) feet
System Type: c 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
•
PERMIT CONDITIONS:
I. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
with applicable norm tardtma beneral statutes, naves for sewage Treatment and ulsposai, and all conamons or me improvement rermt ana tonstruaTdn numortzanon.
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ Ny.�q
If yes, see attached sheet for additional operation a
maintenance and reporting.
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
t1CL Cl�
Septic Tank: � 000' gallons Pump Tank: gallons
Subsurface
No. of
exact length
width of depth of
Drainage Field
ditches
of each ditch `060 feet
ditches feet ditches IRO inches
French'Drain Required: inear feet
Authorized State Agent Date ��