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Harnett County Department of Public Health 21141
PERMIT # as a 6-5- 0 eration Permit
New Installation Z Septic Tank El Repair CNitrifcation Line ❑ Expansion
~--PROPERTY LOCATIO : LrcTo e~-.
Name: (owner) l Inc : I I d ~r ri J_ 'nc SUBDIVISION LOT # r 7 9
System Installer 1 SSQ'_ ja!u% Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms 13
Type of Water Supply: ❑ Community Public ❑ Well Distance from well feet
System Type: 7ff G 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.
Ihis 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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I. Performance: System shall perform in accordance with Rule .1961.
ll. 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 sewa disposal system on the above captioned property.
Type of system: ❑ Conventional Z Other Z Flo,,,) Septic Tank: coo gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch -7 feet ditches feet ditches / 8 "3 G inches
French Drain Required: Linear feet
Authorized State Agent Date /a I
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