OPHTE#14_� Hal..:tt County Department of Publi, Aealth 24261
PERMIT # 1-975-8 —/ 0 eration Pe It
L� New Installation V Septic Tank Nitrification Line ❑ Repair ❑ Expansion
1;IrIl A � 17 UII;I l D] i
Name: (owner) Wyf✓Al C0-QS6*C1= SUBDIVISION LOT # _'_
System Installer: s 1.,,, Registration # O
Basement with plumbing: ❑ Garage JNumber of Adroomis
Type of Water Supply: ❑ Community hd ublic ❑ Well Distance from well feet
System Type: :o— h Types V and VI Systems expire in S years.
(In accordance with Table V a) Owner must contact Health Department 6 months prior to expiration for permit renewal.
This svnem has been installed in
I. Performance:
Il. Monitoring:
III. Maintenance:
IV. Operation:
V. Other.
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
Authorization.
❑ 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 f� Other 25`�� (2d � Sses Septic Tank: l ?eo,0 gallons Pump Tank gallons
Subsurface No. of exact length I width of depth of
Drainage Field ditches of each ditches feet ditches 3 feet ditches 22-51 9 inches
french Drain Required: Linear feet �n
Authorized State Date it — 00 —1 iv