OPHTE# lia rZ54M Harnett County Department of Public Health
PERMIT # a6 b Operation Permit 2 2 31 3
New Installation "iC Septic Tank 'X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: y (L-SS C-.,)
Name: (owner) SUBDIVISION Q49CLG5._.5 Q,-, LOT # ti Q)
System Installer: JsvN 1`'1 ~-ClC~-y Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms 4
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 107 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.
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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rcnrrti Lununwns:
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 captioned property.
Type of system: ❑ Conventional Other I~ 2 ~1.~ Septic Tank: LO0 0 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage field ditchef-~ of each ditch 3C5 0 feet ditches ~ feet ditches 01 !A_ inches
French Drain Required: feet
Authorized State Agent ~ µs Date
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