OPHTE# 13_5"_5)G5IP Harnett County Department of Public Health
PERMIT # '� S'SD Operation Permit 22920
New Installation )K Septic Tank Nitrification Line ❑ Repair ❑ Expansion
�P--_ PROPERTY LOCATION: M ,
Name: (owner) SUBDIVISION C.00ee,-t.. S LOT # �0
System Installer: -o+D Q> Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community K, Public ❑ Well Distance from well a C7C`> feet
System Type: c,. 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.
PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ Nof
If yes, see attached sheet for additional operation cc
IV. Operation:
V. Other:
maintenance and reporting.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above caption roperty.
Type of system: ❑ Conventional ) Other S 0 Septic Tank: gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches l of each ditch feet ditches feet ditches inches
French Drain Reouired: = "`-.,Linea
Authorized State Agent Date
I I �- s .- s ) ral 0