OPHTE - 5µa111 Harnett County Department of Public Health
PERMIT # ago9 Q Operation Permit 22503
New Installation '9� Septic Tank Nitrification Line El Repair El Expansion
PROPERTY LOCATION: �y2s� Poems o
Name: (owner) t 1-a i �2 cz t -,Ems- SUBDIVISION LOT #
System Installer: ® -T, -, � 62- N4-)4a- Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms
Type of Water Supply: ❑ Community ❑ Public 5i� Well Distance from well 1 (n ® 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.
ims system nas been installed in compliance with applicable north larolma beneral )tatutes, Rules for )ewage Ireatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization.
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I. 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 ❑
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional Other SZ VI-Ow Septic Tank:
Subsurface N ' exact length width of
Drainage Field ditches 1 of each ditch ZL0 feet ditches
French Drain Require *� \ \ \cLitfe
Authorized State Agent Date
H2OLine ❑ PWR Line
gallons Pump Tank: gallons
depth of
feet ditches ti`s inches
?I D,- 5- �l) s � �1