OPHTE# I4' �s - 3q&17 Harnett County Department of Public Health 23605
PERMIT # Z $39'0 ep ration Permit
New Installation Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 4/z ---
Name: (owner) 611doi,3 A -,,4 g2& SUBDIVISION LOT #
System Installer: --F41 jq�C m z PG. Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms t
Type of Waterupply: El Community C2'" Public ❑ Well Distance from well %Z feet
System Type: �'���- % t3 Types V and VI Systems expire in 5 years.
(In accordance with fable V a) Owner m� contact Health Department 6 months prior to expiration for permit renewal.
PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
11. 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 ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewa isposal s stem on the above captioned property.
Type of system: ❑ Conventional Other e� �t Septic Tank: 7 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of Z-4 J
Drainage Field ditches of each ditch feet ditches feet ditches inches
French Drain Required: Linear feet
Authorized State Agent Date —G o —Z �