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Harnett County Department of Public Health 21115
PERMIT # 2,5'11 Operation Permit
New Installation X Septic Tank ❑ RepairX Nitrification line ❑ Expansion
PROPERTY LO(ATION: Mbv2y-s V-.b
Name: (owner)FN~.,C-,N C-,\,a<~' 5 SUBDIVISION Pcs~s o LOT # ')O
System Installer: Q-C i5 S ~~~tits~,~w Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms -3
Type of Water Supply: ❑ Community Public ❑ Well Distance from well i no feet
System Type: 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.
1. Performance:
II. Monitoring:
Ill. Maintenance:
IV. Operation:
V. Other.
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No
If yes, see attached sheet for additional operation conditions, maintenance and reporting
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional Other E Z- 'P",,,, Septic Tank: _ gallons Pump Tank: _
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch C) feet ditches 3 feet ditches
French Drain Reauired: i roo+
gallons
inches
Authorized State Agent ~U)43 (0L'"F-0. `SoLxs00F) Date
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