OPDepartment o Public
PERMIT # a��.�� Operation Permit
New Installation.%*I Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: \JAj
Name: (owner) ',rAq4Nv Ca- X10? n(s•7 SUBDIVISION lc-�or,s�, ('�i chi M LOT # c1•iY
System Installer: Cnm )s rt,, Registration #
Basement with plumbing: ❑ GaragesX Number of Bedrooms _7�
Type of Water Supply: ❑ Community Public ❑ Well Distance from well feet
System Type: Thr, 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.
anis system nas peen msiauea in compuance wim appncame norm Larotma uenerae mamtes, rimes for sewage treatment ana
PERMIT CONDITIONS:
I. Performance:
II. Monitoring:
111. Maintenance:
IV. Operation:
V. Other:
699
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 cc
ana an Conaltlons of the Improvement rermlt and Lonstrucnon Mmorizatlon.
tl �P-A'2_�12�A �r
maintenance and reporting.
❑ 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 Other E Z 3 c 1'N Septic Tank: 16 0 Q gallons Pump Tank: D 00 0' gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches _� of each ditch _;L-4.5 feet ditches feet ditches inches
French Drain Required: _I Linear feet
Authorized State Agent K Date i t �-
� �� s� 3 s-�, �