OPHTE# Vs`—s— Harnett County Department of Public Health
PERMIT # X-771),8 Operation Permit 22398
ZNew Installation LSeptic Tank R'_ Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: C1 ���q -�� ✓��
Name: (owner) Y�,,A & SUBDIVISION LOT # V-5—
System Installer: J'!3 Z Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms _J
Type of Water Supply: ❑ Community C" rPublic ❑ Well Distance from well feet
System Type: !-: b 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 Larolma beneral )tatutes, Rules for sewage Treatment and
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and all conditions of the Improvement rermlt and lonstructlon Hutnorizatlon.
PERMIT CONDITIONS:
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:
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❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewap disposaj, system on the above ptioned property.
Type of system: El Conventional Y Other t � •^M v Z` u' Septic Tank: / UU 13 gallons Pump Tank: N 0 d gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch / S`� feet ditches feet ditches �C " (G inches
French Drain Required: Linear feet
Authorized State Agent' �Fr Date
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