OPHTE# `o Harnett County Department of Public Health
PERMIT # Operation Permit 21 61 9
New Installation -"'k Septic Tank ( Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: hoc aC `c-
Name: (owner) \rJ N rj " Cc s~ 2\r c-.< \ o tr SUBDIVISION ?,,3 LO'
System Installer. Q P~~+s3 1 '6~NV-,J Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms 3
Type of Water Supply: ❑ Community -1 Public ❑ Well Distance from well add feet
System Type: , \ V 1 6. Types V and VI Systems expire in 5 years.
(In accordance with Table V a) -Ij Owner must contact Health Department 6 months prior to expiration for permit renewal.
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ims system nas oeen mstauea in compliance wim applicable North tarohna General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization.
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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.
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned pr rty.
Type of system: ❑ Conventional Other Qaewn?'Cn - ( vZ Septic Tank: 1600 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage field ditches o h d feet ditches 3 feet ditches inches
French Drain Reauited: _ a~aQ
Authorized State Agent ` \ \ ° ! \ 4Z)C-A y" Date 9M\0
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