OPI I County Department 11 ,ublic Health
PERMIT # 1r Operation Permit
New Installation Septic Tank Nitri fic tion line ❑ Repair E] Expansion
PROPERTY LOCATION:o�,c,�
Name: (owner) (.v NC— SUBDIVISION LOT #
System Installer: 7—z o 56 Q4,j y t rJ Registration #
Basement with plumbing: ❑ Garage XNumber of Bedrooms
Type of Water Supply: ❑ Community - Public ❑ Well Distance from well 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.
II. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ Nox
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D -Box
Following are the specifications for the
Type of system: El Conventional
Subsurface No. of
Drainage Field es
French Drain Reouired:
El
Pump ❑ Alarm ❑
sewage disposa ystem the aAvve, captioned pro erty.
Other UmQ�� �'�`�C+ti / Septic Tank: 1Q�0
exact length width of 3
of each ditch feet ditches
Linear feet
Authorized State Agent '�'V �' , � — Date '?
1-12O1-ine ❑
PWR Line
gallons Pump Tank: t O DO gallons
depth of
feet ditches IT 3 D inches
koo s �,- , - � �