OPHTE#0 -1 Harnett County Department of Public Health 19 91 5
PERMfr # ~l any Operation Permit
$ - New Installation j0- Septic Tank ❑ RepaipC Nitrification Line ❑ Expansion
PROPERTY LOCATION: t X7'1
Name: (owner) 5 SUBDIVISION LOT #
System Installer. Registration #
Basement with plumbing. ❑ Garage 21 Number of Bedrooms
Type of Water pply: ❑ Community Public ❑ Well Distance from well feet
System Type: M -w' y, ~ Y ) K - ~ , /r tl / /i Types Y 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.
ims system nu Deco ImtaDm is
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with aWcable North Carolina General Statutes, Auks for Sewage Treaanent and Dlsposat, and all coriAtiom of the
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Permit and fomtwon Authm moon.
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Performance: System shall perform in accordance with Rule .1961
Monitoring. As required by Rule .1961.
Maintenance: As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No EK
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
Y. Other.
Following are the specifications for the sewage dispo I system on the above captioned property.
Type of system: ❑ Conventional Other - v• s H Size of tank: Septic Tank: '~12 2 gallons Pump Tank: J~ J gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 1 `6 feet ditches feet ditches D inrh.c
French Drain Required: Unear feet
Authorized State Agent i f L- M-1 Date 3 "