OPHTE#Cj =at7 Harnett County Department of Public Health 21 131
PERMIT # dkras'y QDeration Permit
mew Installation C~eptic Tank ❑ Repair Vitrification Line ❑ Expansion
PROPERTY LOCATIO J5~/
Name: (owner) SUBDIVISION LOT # /7 6
System Installer , :~a~, I v: /d ter. Registration #
Basement with plumbing: ❑ Garage umber of Bedrooms E 3 _
Type of Water Supply: ❑ Community B'-rublic ❑ Well Distance from well feet
System Type: Types V and VI Systems expire in 5 years.
(In accordance with Table V a) Owner most contact Health Department 6 months prior to expiration for permit renewal.
ims system nas peen mstanea in compliance with
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North tarolma General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization
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rLnrni W111101 I Will
1. 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.
Following are the specifications for the se_wsdisposal'ystem on the above captioned property.
Type of system: El Conventional Other C:--" F1oSeptic Tank: Gc~~ gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch /-1-0 feet ditches 3 feet ditches-6' J8 inches
French Drain Required: Linear feet
Authorized State Agentl' K.',,' Aw Date /,//3//,24a 4 5
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