OPHTE# 14 - nett County Department of Public Health
23737
PERMIT # a�� Operation Permit
New Installation ` Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: q 17«�tvs
Name: (owner) t--®� N, ` } tc L t �unesrs� SUBDIVISION LOT #
System Installer: Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms �—
Type of Water Supply: ❑ Community `� Public ❑ Well Distance from well ! ®b feet
System Type: 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 oeen mstaueo in compuance wan appucame north tarouna uenerai statutes, naves for sewage treatment and uisposal, and au conditions 01 the
PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
11. 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 ❑
Following are the sp cifications for the sewage disposal system on the above captioned property.
Type of system: Con entional ❑ Other
Subsurface No
. of exact length
Drainage Field ditches of each ditch feet
French Drain Reouired: c` \ eet
Alarm ❑
Permit and Construction Authorization.
H2O1-ine ❑
PWR Line
Septic Tank: 10 0 ® gallons Pump Tank: gallons
width of depth of
ditches 3 feet ditches )?-36_ inches
Authorized State Agent _ �__ '�E Date `8