OPHTE# C I- — 3 Harnett County Department of Public Health
PERMIT # ' Sr `" ( Operation Permit 22610
mew Installation ® Septic Tank 2— Ifitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:
Name: (owner) `-t t SUBDIVISION r. ` LOT #
System Installer: Registration '#
Basement with plumbing: ❑ Garage qu, m r of Bedrooms 3
Type of Water Supply: ❑ Community lic ❑ Well Distance from well l G C feet _r4_
System Type: Types V and VI Systems expire in 5 years.
(In accordance with Table V ar Owner must contact Health Department 6 months prior to expiration for permit renewal.
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:
D -Box ❑ Pump ❑ Alarm H2OLine IE9 PWR Line
Following are the specifications for the sewa ge disposals stem on the above captioned property.
Type of system: ❑ Conventional Z Other I (Alo_l Septic Tank: 1066 _ gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch feet ditches feet ditches inches
French Drain Required: Linear teet
Authorized State Agent ° �„f t — Date