OP RHTE# Iq--s"-3ygSyHarnett County Department of Public Health 23575
PERMIT OOeration PIt
er
/New Installation Septic Tank 1 Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:a2�yi9 6 k" ��.x� �
Name: (owner) SUBDIVISION 7 ' LOT #
System Installer: Ta Registration #
Basement with plumbing: ❑ Gara(❑ Number of�Bedd s .3
Type of Water Supply: _❑ Community ❑ Public L� Well Distance from well feet
System Type: r-x.X�5 c54 -G— ( �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.
c�-
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 ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D -Box ❑ Pump ❑
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional ❑ Other
Subsurface No. of _ exact length
Drainage Field ditches of each ditch feet
Alarm ❑
H2OLine ❑
Ne.)
Septic Tank:/ 00 gallons Pump Tank:
width of _ depth of
ditches feet ditches
French Drain Required: Linear feet
Authorized State Ag Date `i ' ► " % s'
PWR Line
gallons
inches