OPCountyDepartment of PublicHealth
PERMIT #Operation Permit
New Installation '�R Septic Tank �R' Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: t` cLlr-_;,�q QiWisj_ CNC vQ.ra-`ii, Q,
Name: (owner) w t IH SUBDIVISION LOT #
System Installer: c.Y..- o N Registration # V 9z \ 7
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms
Type of Water Supply: El Community >� Public El Well Distance from well L 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 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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PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
IL 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:
Other: C.-, V sty 3(." 4JC.,Le
❑ D -Box ❑ Pump ❑ Alarm ❑
H20Line ❑
PWR Line
Following are the specifications for the sewage disposal system on the abov capti property.
Type of system:
El%,Other �A ���` Septic Tank: t Ob 0 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 5 0 feet ditches _S feet ditches , inches
French Drain Linear feet
Authorized State Agent Date -J1��