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HTE# lo-s-a~,3s Harney County Department of Public Efith
PERMIT # Operation Permit 21 7 5 4
New Installation ~R Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: "wj2Q '~A
Name: (owner) \,I -Y ;t4 C-0~:5;a,vcfs\ c, r4 1w c- SUBDIVISION LOT # tU
System Installer: lo~sor5 ~~~~,v Registration #
Basement with plumbing: ❑ Garage 'E~ Number of Bedrooms 3
Type of Water Supply: ❑ Community ~K Public ❑ Well Distance from well 1UO feet
System Type: -o, 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.
inns system nas Deen mstanea in
with applicable North larohna beneral Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization
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1. 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 ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other.
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional 1 Other EZ '~7u0w Septic Tank: tOC~0 gallons Pump Tank: gallons
Subsurface No. of - exact length width of depth of
Drainage Field ditches each ditch ~6 feet ditches 3 feet ditches 1Q inches
French Drain Required: Linear
Authorized State Agent ~J~, . Y:~- s _ Date 10 11 ~
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