OPHTE# O -s- a~ y 3R Harnett County Department of Public Health 2 0 9 8 3
PERMIT # ~y Uperation Permit
New Installation X Septic Tank ❑ Repair 1~( Nitrification Line ❑ Expansion
PROPERTY LOCATION: 113')
Name: (owner) pw'~ % br,' cs SUBDIVISION f Q 1 z c. LOT # S-q
System Installer. L. SkA2,pc. Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: Community Public ❑ Well Distance from well 103 feet
System Type: / 2C C -p) = 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.
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With applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal and all conditions of the
Permit and [onstruction Authorization.
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iPFRMIT rmmnlTlAW-
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1. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring. As required by Rule .1961.
111. 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.
Following are the specifications for the se age disposal system on the above captioned property.
Type of system: ❑ Conventional ther (LL Septic Tank: gallons Pump Tank: gallons
Subsurface No. of f exact length width of depth of
Drainage Field ditches 1 of each ditch feet ditches feet ditches inches
French Drain Required: Linear feet
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Authorized State Agent_~\ ~~T;~- U ~ Date ~ DAC
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