OP RQ_ Department of Public
N.
PERMIT # 2--� Operation Permit
New Installation X Septic TankNitrification line ElRepair ElExpansion
PROPERTY LOCATION: tfLg_ It
Name: (owner) �J(avv y 1-1 d�,�s SUBDIVISION r, LOT #
System Installer: Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms 9
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 100 feet
System Type: T11`1� 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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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 ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage disposal system gjthe above captioned property.
Type of system: El Conventional Other F'U,' 1 ° E Z R� Septic Tank: 1000 gallons Pump Tank: 100 Cs gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches 1 of each ditch .1 '-1 ® feet ditches feet ditches i inches
French Drain Reouired: ^� Linear feet
Authorized State Agent e)5 Date —7
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