OP RRRRHTE# �� �'3`��Q 6reQ Harnett County Department of Public Health 23706
PERMIT # 0288 9 Operation Permit �/
led New 'Installation Tank E /Nitrification Line ❑ Repair ❑ Expansion
rf PVT PROPERTY LOCATION: J oa ( S vanr cit Ad
Name: (owner) r,,,ye ii�): (cox LeorA;25 Ce-,clie,SUBDIVISION LOT #
System Installer. dA,P— 6c�ec Registration #
Basement with plumbing: ❑ Garage ElNumber of Bedrooms %,fes -7" 4 aG
J
' -'o I-XeeZ
Type of Water Supply: EJ Community ❑ Public ❑ Well Distance from welt' feet
System Type: -2z6 Types V and VI Systems expire in S years.
(In accordance with Table V a) Owner must contact Health Department 6 months prior to expiration for permit renewal.
ims system nas seen minutes in nmouana wstn aommame norm Urolma General
PtKMII tunmuuxs:
I. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
V. Other.
4PAcl?-
A/ -c A
and all conditions of the
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
Permit and Consinmon Authorization.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLims ❑ PWR Line
Following are the specifications for the sew a disposp�I system on above captioned pro erty. 10003rd
Type of system: ❑ Conventional (Other 7�y+.(a'�G cry,t�'a�.u,a� Septic Tank: 00 gallons Pump Tank: /,r00 gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches .f of each ditch /510 feet ditches 3 feet ditches 3o"2y inches
French Drain Requl Linear feet
Authorized State Agent Date 101
8j -391'7e( 42 CIL
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