OPHTE# Harnett County Department of Public Health 21358
PERMIT # a-5°113 Operation Permit
New Installation P~ Septic Tank ❑ Repair, Nitrification Line ❑ Expansion
PROPERTY LOCATION: Po-4oErLOgQ,
Name: (owner) ~►~r,,ES SUBDIVISION LOT #
System Installer: Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms rs
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 1 COO feet
System Type: T r 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: System shall perform in accordance with Rule .1961.
If. 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: tJo S~E~ MOVGo P.-C ~Qv t g~ OF
V. Other V p'1K ! flaAi«L~~t.s p-go,► C-~tGG cED O+~ 3 ~0 ~y <3'V '4 P~ F LiNfo k Uy,&- L -3 5-r , LL'"ro
s ~H ysU,".rzo ` Cl~ S)b7)1p~0~rEn ¢u~ D 2t~L
Following are the specifications for the sewage disposal.Etem on the above captioned property.
Type of system: ❑ Conventional Other 1 M Z C.ti V P 5 Septic Tank: gallons Pump Tank: gallons
1 `a..5d
Subsurface No. of exact length width of depth of
Drainage field ditches of each ditch 1 ~1 feet ditches feet ditches inches
French Drain Reauired:,
Authorized State Agent Date 511X 110
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Central Carolina Holdings, LLC
1616 McK(* Town Road
TRAILER OUT Camer C. 28326
9199+-2301
'
TRAILER IN: Fax: 919.499-4619
NC Watts: 1.800-232-0035
rj 'tea
_ Date - I /
CUSTOMER
ADDRESS F Time
Driver
Passenger Car Tires # # 4
Tractor Trailer Tires # 1
Farm Tractor Tires #
Other # w
PER LOAD This load of tire chips Is from the Fuel Grade location and meets the Nc specMtcan" of
stated in Innovative Wastewater system approval IWWS•2002-03k for *0 chip
Weight Empty substitution for Rock AgWeprald In NitdNcatton Fields.
Weight Loaded
Total Tonnage of Tires Customer Signature
Terms: Net 15th Following Statement
WHITE COPY - OFFICE CANARY COPY - FILE PINK COPY - OFFICE GOLD COPY - CUSTOMER
CCTD DBA B.T. Sanitation, Inc.