OPHTE #,:� 1 Harnett County Department of Public Health
PERMIT # QL�-1 C-, Operation Permit 22561
New Installation X Septic Tank Nitrification line ❑ Repair ❑ Expansion
�- PROPERTY LOCATION:_ Do('a
Name: (owner) 'Yt-,� t-.j SUBDIVISION 1 tz -s( --.(4 a c c... LOT # \LA
System Installer: ���ccz:c) ��,� �,����,c,�t Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms L
Type of Water Supply: ❑ Community 'IS( Public ❑ Well Distance from well feet
System Type: r 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
rtnrnl LuNuiiivi43:
I. Performance: System shall perform in accordance with Rule .1961.
11. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ Nox
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑
Following are the specifications for the sewage disposals stem on the above captioned property.
Type of system: ❑ Conventional ` Other Z �ekw Septic Tank: iC� O gallons Pump Tank: _
Subsurface - ..No., of \ exact length width of depth of
Drainage Field ditches of each ditch A00 feet ditches feet ditches
French Drain Reouired: I I ,Linear feet
Authorized State Agent ___ ° • Date
PWR Line
gallons
inches
i,2, -5-- lac e 1