OP RHTE °-?-17 S-"iZ- Harnett County Department of Public Health
PERMIT # �"� �-2 0 ep ration Per it / 22684
New Installation Septic Tank ® Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: —1 L 7
Name: (owner) f SUBDIVISION . a LOT # f
System Installer: ' o Registration #
Basement with plumbing: ❑ Garage ❑ umber of Bedrooms S
Type of Water Supply: ❑ Community L Public ❑ Well Distance from well feet
System Type: 67 g Types V and VI Systems expire in 5 years.
(In accordance with Table V a) Owner must co act Health Department 6 months prior to expiration for permit renewal.
I. Performance:
II. Monitoring:
III. 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.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional V Other 05'06 r Septic Tank: / gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 9c,0 feet ditches feet ditches Z q inches
French Drain Required: Linear feet
Authorized State Ag Date -7, —/