OP RRRHTE#/ 5-4' � 7 4
PERMIT #s
Hai -at County Department of Publik. Aealth 23798
Z New Installation Septic Tank L3' Nitrification Line ❑ Repair ❑ Expansion
��e� PROPERTY LO(ATION: LJ`7 cOZ
Name: (owner) I/�„���� �la`i cA� SUBDIVISION �l LO,
System Installer: ! Registration #
Basement with plumbing: ❑ 1 Garage ember of Bedrooms
Type of Water Supply: El Community LST Public ❑ Well Distance from well feet
System Type $-% GllS Du crt ? f Types V and VI Systems expire in S years.
(In accordance with Table V a) Owner must confilli Health Department 6 months prior to expiration for permit renewal.
PERMIT CONDITIONS:
I. Performance:
11. 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.
❑ D -Box ❑ Pump ❑ Alarm ❑ 1-1201-ine ❑ PWR Line
Following are the specifications for the sews disposals stem on the above captioned property. ����
Type of system: ❑ Conventional 71 ther l_ °7o y2Aa67i.�.� r/'!� Septic Tank: — ,066 gallons Pump Tank: gallons
Subsurface No. of q exact length % width of depth of
Drainage Field ditches of each ditch 1O0 feet ditches 3 feet ditches Z4V inches
French Drain Required: Linear feet
Authorized State Age Date /a _ z t —i 3 —
13-5-3092ORR (1)
13-5-3092ORR (2)
13-5-3092ORR (3)
13-5-3092ORR (4)
13-5-3092ORR (5)
13-5-3092ORR (6)
13-5-3092ORR (11)
13-5-3092ORR (7)
13-5-3092ORR (8)
13-5-3092ORR (9)
13-5-3092ORR (12)
13-5-3092ORR (13)
13-5-3092ORR (14)
13-5-3092ORR (10)