OP RHTE#QM7 -5- 1(:jsI Harnett County Department of Public Health
PERMIT #Operation Permit 2 2 21 6
New Installation ~k Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:_
Name: (owner) "L-1. z~ \A0 t~ SUBDIVISION _.._C p~~~ LOT # .4
System Installer: W N i:- ~o"C,e Registration #
Basement with plumbing: ❑ Garage >9~ Number of Bedrooms -3
Type of Water Supply: ❑ Community Public ❑ Well Distance from well -10 0 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.
1. 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 ❑ No
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other.
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewage disposal system on the above ca tioned property.
Type of system: ❑ Conventional ~ Other Qv,,yY,ef Septic Tank: V00 9 gallons Pump Tank: gallons
Subsurface of exact length width of depth of
Drainage Field of each ditch ~a feet ditches 3 feet ditches inches
French Drain Required: m fast
Authorized State Agent Date _ ~Zf 1
w.
r
~
j
'
~
n