OPHarney County Department of Public hicalth
PERMIT # aG~~~l Operation Permit 2 21 5 0
New Installation Septic Tank X Nitrification Line ❑ Repair El Expansion
PROPERTY LOCATIO : ~0 ,1- L--y as
Name: (owner) lR> r~N®.e-) VAOmC-s t"tC- SUBDIVISION LOT # _
System Installer: M N m-- tel~i Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 100 feet
System Type: a 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,
tms system nas Deen mstaueo in compuance witn appucabfe north t.arohna beneral Statutes, Rules for Sewage Ireatment and Disposal, and all conditions of the
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Permit and Construction Authorization.
rtKMIl LUNUIIlUNY
1. Performance: System shall perform in accordance with Rule .1961.
11. 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:
❑ D-Box ❑ Pump ❑
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: El Conventional Other C Z \ L,<3-r,/
Subsurface No. of exact length
Drainage Field ditches of each ditch 18 0 feet
Alarm ❑ '
Septic Tank: t 00 °
width of
ditches
H20Line ❑ PWR Line
_ gallons Pump Tank: gallons
depth of
feet ditches inches
trench Drain Required: linear feet
Authorized State Agent as Date 11D 1 1~ N)