OPHTE# 14-5 - ZgT30 Harnett County Department of Public Health 21 0 4 2
PERMIT # Z (¢O S'q Operation Pe it
ZNew Installation IJ~ Septic Tank ❑ Repair 5 Nitrification Line ❑ Exoanstnn
PROPERTY LOCATION:,-/yo3
Name: (owner) % - SUBDIVISION p~ A LOT #
System Installer. Registration #
Basement with plumbing: ❑ Gara e ❑ umber of Bedrooms -S
Type of Water Supply: ❑ Community Public ❑ Well Distance from well feet
System Type: Z-M/24GYfZdo~~Crw ,E'&&, r3 Types V an VI Systems expire in 5 ars.
(In accordance with Table V a) Owner must contact Health Dep rtment 6 months prior to xpiration for permit renewal.
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewa¢e Treatment and
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Permit and Construction Authorization.
PERMIT CONDITIONS: S;Z /9o3 1k"
1. 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.
Following are the specifications for the sewwee disposal system on the above captioned property.
Type of system: ❑ Conventional Lid Other Septic Tank: 10'10J gallons Pump Tank: gallons
Subsurface No. of exact lengt width of depth of
Drainage Field ditches I of each ditch Z C7 feet ditches 3 feet ditches Z° 4l Q, inches
French Drain Required: Linear feet
Authorized State Agen Date g' 3-/Q
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