Boone Trail Emerg. Svs. Application for RepairPHYSICAL
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
307 W. CORNELIUS HARNETT BLVD.
LILLINGTON, NC 27546
910-893-7547 PHONE
910-893-9371 FAX
Application for Repair
I
EMAIL ADDRESS: 4&L //lfrr.ryy %a% �64r C2
MAILING ADDRESS (IF DIFFFERENT THAN PHYSICAL)
IF RENTING, LEASING, ETC., LIST PROPERTY OWNER
SUBDIVISION NAME
Type of Dwelling: []Modular
Number of bedrooms
Garage: Yes[] No[]
Water Supply: [ ] Private Well
LOT #/TRACT # STATE RD/H WY ,�" SIZE OF LOT/TRACT
[ ] Mobile Home [ ] Stick built I9 Other Y" x -
[ ] Basement „Z `Z 9 Q y
-f`
Dishwasher: Yes [ ] No [ ] / Garbage Disposal: Yes [ ] No [ ]
[ ] Community System W16ounty
Directions from Ullington to your site:
In order for Environmental Health to help you with your repair, you will need to comply by completing the following:
1. A "surveyed and recorded map" and "deed to Your orooerty" must be attached to this application. Please inform us of any
wells on the property by showing on your survey map.
2. The outlet end of the tank and the distribution box will need to be uncovered and property lines flagged. After the tank is
uncovered, property lines flagged, underground utilities marked, and the orange sign has been placed, you will need to call
us at 910-893-7547 to confirm that your site Is ready for evaluation.
Your system must be repaired within 30 days of issuance of the Improvement Permit or the time set within receipt of a violation
letter. (Whichever is applicable.)
By signing below, I certify that all of the above information is correct to the best of my knowledge. False information will result in
the denial of the permit. The permit is subject to revocation if the site plan, intended use, or ownership changes.
Date
HOMEOWNER INTERVIEW FORM
It is important that you answer the following questions for our inspectors. Please do not leave any blanks if
possible, and answer all questions to the best of your ability. Thank You.
Have you received a violation letter for a failing system from our office? [ ] YES [ ] NO
Also, within the last 5 years have you completed an application for repair for this site? [ ] YES [ J NO
Year home was built (or year of septic tank installation)
Installer of system
Septic Tank Pumper
Designer of System
1. Number of people who live in house? # adults # children # total
2. What is your average estimated daily water usage? gallons/month or day county
water. If HCPU please give the name the bill is listed in
3. If you have a garbage disposal, how often is it used? [ ] daily [ ] weekly [ ] monthly
4. When was the septic tank last pumped? How often do you have it pumped?
5. If you have a dishwasher, how often do you use it? [ ] daily [ ] every other day [) weekly
6. If you have a washing machine, how often do you use it? [ ] daily [ ] every other day [ ] weekly [ ] monthly
7. Do you have a water softener or treatment system? [ ] YES [ ] NO Where does it drain?
8. Do you use an "in tank' toilet bowl sanitizer? [ ] YES [ ] NO
9. Are you or any member in your household using longterm prescription drugs, antibiotics or
chemotherapy?] [ ] YES [ ] NO If yes please list
10. Do you put household cleaning chemicals down the drain? [ ] YES [ ] NO If so, what kind?
11. Have you put any chemicals (paints, thinners, etc.) down the drain? [ ] YES [ ] NO
12. Have you installed any water fixtures since your system has been installed? [ ] YES [ ] NO If yes,
please list any additions including any spas, whirlpool, sinks, lavatories, bath/showers, toilets
13. Do you have an underground lawn watering system? [ ] YES [ ] NO
14. Has any work been done to your structure since the initial move into your home such as, a roof, gutter
drains, basement foundation drains, landscaping, etc? If yes, please list
15. Are there any underground utilities on your lot? Please check all that apply:
[ ] Power [ ] Phone [ J Cable [ ] Gas [ ] Water
16. Describe what is happening when you are having problems with your septic system, and when was this
first noticed?
17. Do you notice the problem as being patterned or linked to a specific event (i.e., wash clothes, heavy
/lairs, andel household guests{J??A[ ] YES [ ] NO If Yes, please list
B NEI it COUNTY HEALTH DEPAY IENI
ENVIRONMENTAL HEALTH SECTION
OPERATIONS PERMIT
Name: (owner)±]QAC T,s.
Property Location: SR# y2/ 4/
Subdivision
No 15490
❑ New Installation ❑ Septic Tank
YR^eD5'airs/I 4. op Nitrification Line
Lot #
�
J TAX ID# Quadrant #—
Contractor: /"2 4c- & Registration #
Basement with Plumbing: Garage:
Water Supply: Well �blic ❑ Community
Distance From Well: d�d ft.
Following are the specifications for the sewage disposal system on above captioned property.
Type of system: ❑ Conventional 0 Other Pi f+P t. C ✓t °—
Size of tank: Septic Tank: E J -- gallons Pump Tank: �- gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches j of each ditch J ft. ditches 3 ft. ditches2—�� in.
French Drain: Linear feet
Date: Z 12sl-lze--7 r
PERMIT NO. —Z2LI Inspected by: 44,/�' -_/ r
'k Aaa f .lk- k. SY,k<I�'k
�Z /
UT300G0I COUNTY OF HARNETT PUBLIC UTILITIES
Customer/l, tion Consumption History
Location ID: 77150 Addr: 7016 US 421 N
Customer ID: 55455 Name: BOONE TRAIL EMERGENCY SERVICES
Service . : WA WATER
Period
Actual Consumption
Days
Daily consumption
03/15
7,370.00
26
283.46
02/15
6,380.00
30
212.67
01/15
7,850.00
38
206.58
12/14
6,340.00
29
218.62
11/14
6,040.00
29
208.28
10/14
6,150.00
29
212.07
09/14
5,260.00
29
181.38
08/14
5,570.00
32
174.06
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12/16/15
10:13:33
F17=Subset
13
UT300G01
COUNTY OF
HARNETT PUBLIC UTILITIES
Customer/L
tion Consumption History
Location
ID: 77150 Addr: 7016 US 421
N
Customer
ID: 55455 Name: BOONE TRAIL
EMERGENCY SERVICES
Service
: WA WATER
Period
Actual Consumption
Days
Daily consumption
11/15
18,170.00
33
550.61
10/15
17,500.00
30
583.33
09/15
17,600.00
30
586.67
08/15
15,740.00
32
491.88
07/15
15,750.00
31
508.06
06/15
10,990.00
27
407.04
05/15
10,050.00
32
314.06
04/15
8,160.00
32
255.00
12/16/15
10:13:00
13
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UT300I01 COUNTY OF u4RNETT PUBLIC UTILITIES 1/05/16
Customer/Locati Consumption Pending Inquiry 08:5 n'^
Customer ID: 55455 Name: BOONE TRAIL EMERGENCY SERVICES �a
Location ID: 77150 Addr: 7016 US 421 N 13
Cycle/Route: 05 05 Amount due: $.00
Initiation date : 1/01/93 Pending $.00
Termination date: 0/00/00 Customer status: A Customer/Location status: A
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Service Reading Actual Actual Meter Est Cant
Opt Code Type Date Consumption Demand Days Number CD CD
WA REG 12/28/15 7110.00 .00 33 22360914 N
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