OPHTE# 57 5bo- I &13 z Harnett County Department of Public Health 2 0 7 2 9
PERMIT # a operation Permit
CIS--New Installation~~eptic Tank ❑ Repait~Nitrification Line ❑ Expansion
2-- ell PROPERTY LOICATION: ll `f/
Name: (owner) -L S2 t s SUBDIVISION SQ /0, LOT # 1.
System Installer: 2~c~r Registration #
Basement with plumbing: ❑ Garage J Number of Bedrooms '3
Type of Water Su lly: ❑ Community >~r Public ❑ Well Distance from well feet
System Type: (eta r C 'k L( 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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1. Performance:
If. Monitoring
III. Maintenance:
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other.
IV. Operation:
Subsurface system operator required? Yes ❑ No
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
V. Other
following are the specifications for the sewa a disposal stem on the above captioned property.
Type of system: ❑ Conventional Other r Septic Tank: O %3 C-1 gallons Pump Tank: gallons
Subsurface No. of exact length ~ ~ width of depth of
Drainage field ditches of each ditch 13 feet ditches _3 feet ditches inches
French Drain Required: Linear feet
Authorized State Agent Date "
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