OPHTE# la.,-5•Harnett County Department of Public Health
PERMIT it a`~O❑G~ Operation Permit 2 2 4 2 4
New Installation ~K Septic Tank `C Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: "'tiN~f~N V--p
Name: (owner) \j % --S)5 1N L SUBDIVISION ABC d NS -0 LOT # G 0
System Installer: S-v " Registration #
Basement with plumbing: ❑ Garage 'X Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well S b d feet
System Type: » 1 c4 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 an conditions of the improvement rermDt and Lonstruaion autnonzaaon.
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PERMIT CONDITIONS:
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 ❑ N
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 spe
Type of system: ❑
cifications for the sewage disposal ~s.Ystem on the above captioned property.
Conventional ?S~ Other Le ~1-a W Septic Tank: fO®O
gallons Pump Tank: gallons
Subsurface
Drainage Field
No. of exact length width of
ditches of each ditch 90 feet ditches 3
depth of
feet ditches inches
French Drain Reauired: et
Authorized State Agent t-ey Date
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