OPHTE #J a -5-3 9 Harnett County Department of Public Health
PERMIT # �-s Operation Permit 22882
New Installation A Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: C,�gyp
Name: (owner) av s) Cv n. r^ , SUBDIVISION LOT #
System Installer: !V-L, �5 ac-1- C Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well t CS9 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 LI\I111 LWIVIIIVI \J.
I. Performance: System shall perform in accordance with Rule .1961.
11. 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:
❑ D -Box ❑
Following are the specifications for the
Type of system: ❑ Conventional
Subsurface No. of
Drainage Field "ditfhes�
French Drain Reauired�-_
Pump ❑ Alarm ❑ H2OLine ❑
sewage disposal system on the above captio d property.
Other -`.its n Septic Tank: ItQQ gallons Pump Tank:
exact length width of depth of
of each ditch S® feet ditches -T2) feet ditches
Authorized State Agent q_E)AS Date
PWR Line
gallons
inches