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OPHTE# Z800 Harnett County Department of Public Health PERMIT 1Operation Pe it 2 2 2 6 9 New Installation Septic Tank Nitrification Line ❑ Repair ❑ Expansion PROPERTY LOCATION:5it-i!7 5 Al Name: (owner) L SUBDIVISION LOT # _ System Installer: Registration # Basement with plumbing: ❑ Garage Et Number of edrooms Type of Water Supply: ❑ Community 0 Public ❑ Well Distance from well feet System Type: ?t ar~s"Le : , n,4 Fes- _ 6` G 10111~es V and VI Systems expire in 5 years. (In accordance with Table V a) Owner must contactlealth 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 rtKMII wnuitwnx 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 ❑ 1-1201-ine ❑ PWR Line Following are the specifications for the sewage disposal system on the above captioned property. Type of system: ❑ Conventional EZ Other S`*& w? M '•lt~.. 14~- jjz f Septic Tank: r1 gallons Pump Tank: gallons Subsurface No. of exact length width of depth of A Drainage Field ditches of each ditch feet ditches 3 feet ditches s~ L3 inches French Drain Required: Linear feet Authorized State Ag Date ^ 2I;, -M Wl c~ 12-5-28130 (1) 12-5-28130 (2) 12-5-28130 (3) 12-5-28130 (4) 12-5-28130 (5) - A. ~ .i / _~:.ifx. {4. .L :ice 3. ♦ - t 12-5-28130 (6) 12-5-28130 (7) 12-5-28130 (8) 12-5-28130 (9) 12-5-28130 (10) - 3A~z r - a e r - Eli` 12-5-28130 (11) 12-5-28130 (12) 12-5-28130 (13) 12-5-28130 (14) 12-5-28130 (15) 12-5-28130 (16) 12-5-28130 (17) WELL CONSTRUCTION RECD ~J-jO7~ a 2. WELL LOCATION- Nearest i TapograPhiclLand Nearrst Townti_ r Coc~ty I I~ rn P- CIRldge C3Sbpe Majlsetfmg ey A lat (cboet appropdzJcbaa) (Strut Nanv& Numbas, Cammuoity. Snbdivisicn. I& No,. Zip Code) Latitudeilawitade of well location 3. OWr e l rx f (-~O ~ Address 17 t~' 1)7 i e Latitude4ongitade source:OGPSCI' (Saves orRoute No,) {eb&k box) ~J~p f,> U n n IU G 3 =f p I2BILLING LOG City or Town State Zip Code From To - Areacode pboso number I - o 4. DATE DWLLI~D_ 3 - c) 5. TOTAL DEPTH: O F7- -ta;i, IA I/ 6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 's a -C 7. STATIC WATER LEVEL Below Top of Casing: f FT, - D -a D Nee "e if Above Top ofCasing) D S. TOP OF CASING IS FT. Above Land Surface* *Top of eadna terminated Wor below land saaftea requires a variance in aeeordance with 15ANCAC 2C.0118. 9. YIELD tgpm}:_ METHOD OF TEST uj''1 in 10. WATER ZONES (depth}: ~ - d - LOCATION SKE= 11. DISINFB ON: Type Amount - .2 C'" oes Show direction and distance in miles from at least 12 CASING: Well Thidmess two State Roads or County Roads. Include the road Depth Diameter or Wei numbors and common road names. $G O = O Mc ~:l Ft. Y art L From.,- To Ft y 13. GROUT: Depth Material Method From- Ta-A-Q- Ft 1 an " -I-e fh li From To - Fk 14. SCREEN. Depth. - Fro m c TT;-! Ft. in- ' t91iL VC_ Lon y taranGh Rd Frolq 68 To~ Ft in. D in. 15. SANDIGRAVEL PACK From To th S, r Ft_ _iL9 Ct/< -L ' S- From To Ft.16. REMARKS: 's ri t%~ I DO HEREBY CERTIFY THAT THM WELL WAS CONSTRUCTED IN ACCORDANCE WITH ISANCAC XC WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF TJHS RECORD HAS BEEN PROVIDED TO THE-WELL OWNER SIGNATURA OF PERSO]9 CONSTRUCMG TTiE WELL DATE Submlt the original to the Divislon of Water Quality, Groundwater Section, 16M Kau Savioe CeuUr _ fiC 2709-1636 No. (919) 733,1221, wMn 30 days. ©W-1 REV. 07/2001 afia& P