OPHTE#%O-,5-- z3ew`r Harnett County Department of Public Health 21 3 0 5
PERMIT # eration Permi
New Installation Septic Tank El Repair Rl Nitrification Line O Expansion
PROPERTY LOCATION: , r>r 4- 'd/.
Name: (owner) SUBDIVISIONd L 0 T # 1,16
System Installer: Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community e--Public ❑ Well Distance from well 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.
This 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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1. Performance: System shall perform in accordance with Rule .1961.
11. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No RT"
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other.
Following are the specifications for the sewsISposal system on t above captioned property.
Type of system: ❑ Conventional Z Other [ 7- "r Septic Tank: l gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch ~d feet ditches 3 feet ditches inches
French Drain Required: Linear feet
Authorized State Agenf _ Date Z~`
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