OPHTE# 10 -5 -a43a~ Harnett County Department of Public Health
PERMIT # Operation Permit 21 6 0 2
New Installation X Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:
Name: (owner) Cr-bEnL.,--^"j0 lNoM~cS SUBDIVISION `loe`~-sH~cG P,- NON LOT # V~Q
System Installer. \ T=o geo w " Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well tOQ feet
System Type: -Z11 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.
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this system has been installed in compliance with applicable North Carolina eneral Statutes, Rules for Sewage Treatment and isposal, and all conditions of the Improvement Permit and Construction Authorization.
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1 LIII 111 I - IIV 1\J.
1. Performance:
II. Monitoring:
III. Maintenance:
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other:
IV. Operation:
Subsurface system operator required? Yes ❑ No'5k
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
V. Other
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❑
D-Box ❑ Pump ❑ Alarm ❑
H20Line ❑
PWR Line
Following are the specifications for the sewage disposals stem on the above captioned erty.
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Type of system: ❑
Conventional A Other
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,17 Septic Tank: t b00
gallons Pump Tank:
gallons
Subsurface
No. of exact length width of
depth of
Drainage Field
ditches of each ditch feet ditches 3
feet ditches
inches
French Drain Reauired:
I innar blot
Authorized State Agent : \~~,A~°`~~ (L C >a5 Date f ~tia
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