OPHTE# r Harnett County Department of Public Health
23077
PERMIT # F 5 Operation Permit
Lam' New Installation a- -Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: L
Name: (owner) d ��%, SUBDIVISION U1 LOT #
System Installer: Registration #
Basement with plumbing: ❑ Garage ZL- Number of Bedrooms
Type of Water Supply: ❑ Community u lic ❑ Well Distance from well — feet
System Type: JAC a Types V and VI Systems expire in S years.
(In accordance with Table V a) Owner must contact Health Department 6 months prior to expiration for permit renewal.
rtnMu Lununiuns:
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 ❑ No 9-*"'
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D -Box ❑ Pump ❑ Alarm C� H2OLine ❑ f PWR Line
following are the specifications for the sewage disposal sys a on the above captioned property.
Type of system: ❑ Conventional f�Other j t, Y +tllS` Septic Tank: gallons Pump Tank: gallons
Subsurface No. of exact length width of _" depth of
Drainage Field ditches of each ditch feet ditches 7 feet ditches inches
French Drain Required: Linear feet
Authorized State Agent 41-12 Date o/w/r,