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PERMIT # ;Q 4)�5 Operation Permit 22843
New Installation X Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 0N '0fD_X)5ca
Name: (owner) �6rn SUBDIVISION Ca•2,ao,'P, -. ot1S LOT # 10
System Installer: \x4 %;�j �50 �G Registration #
Basement with plumbing: ❑ Garage X Number of Bedrooms `)
Type of Water Supply: ❑ Community 'I.V, Public ❑ Well Distance from well 0(2 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.
finis system nas oeen mstanea in compoance wim appucame norm carmma uenerai xatutes, nines mr sewage ireatment ana uisposai, ana an conamons m me
100
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PERMIT CONDITIONS:
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:
rerm¢ ana construction autnorrzation.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage disposal system on the aboyecaptiam�( property.
Type of system: El Conventional Other Qt s�(L _ l� Septic Tank: 100 0 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field di es of each ditch O® feet ditches feet ditches inches
French Drain Required: - linear
Authorized State Agent �� "' Date `111 C
13 -5 - 3 aqs-5