OPHTE# CYR- 5-4C>36-Q Harnett County Department of Public Health 21 4 51
PERMIT #041 *9tl0n Permit
New Installation -tg, Septic Tank ❑ Repair X Nitrification Line ❑ Expansion
PROPERTY LOCATION _N
Name: (ownerE„4Y~ ~t^L~ X0"):5 SUBDIVISION LOT #
System Installer: NN P S QL Registration #
Basement with plumbing: ❑ Garage ❑ NwmbeFof wFeems 3c+o,..,Ero~z c,unc,s
Type of Water Supply: ❑ Community ~K Public ❑ Well Distance from well i oo 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.
I. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
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-X
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
V. Other. Gc>z~ ~ar~p 1N~-._~t~ cs~ 4>r, Ns~ Co rC c; ~,~cti u a w .
t son g~\
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional Other ~L,MP ~a Co~y~•rCio r.,S~~ Septic Tank: 91a0C~- gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 10 feet ditches 3 feet ditches 8k Li inches
French Drain Reouired: _ 1;nom feet
Authorized State Agent ~n!i ~ Date 5
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