OPHTE# o -5-a~s~s Harnett County Department of Public Health
PERMIT # 'a 'A1~ 0 eration Permit 21 5 9 3
New Installation . Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: a.~l W E5 s
Name: (owner) ~ `f ~ ~ Cy cL~ L~ ~ ~ ~ SUBDIVISION \ t a ck" R 0-, t- t LOT #
System Installer: R P~N9~1 bs>.~~ ~N Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 1PS) feet
System Type: °"C_ .1l, Q, 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.
ims system nas been installed in
with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization
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1 Lill 111 I.VIt V111V1\J.
1. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As required by Rule .1961.
111. 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 ❑ H201-ine ❑ PWR Line
Following are the specifications for the sewage disposal system on the abpve captioned prop
Type of system: ❑ Conventional X Other ~NA~SCR l~U Septic Tank: 1 C b6 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch a6o feet ditches 3 feet ditches a'o inches
French Drain Reauired: l.fan~
Authorized State Agent__ A~ ~w~~ Date 31 v41 10
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