OPHTE# 9-1-S-ICo1 r Harnett County Department of Public Health
PERMIT # 9-yg l il- 0 eration Permit 21 6 2 2
New Installation Septic Tank x Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: HMV Et_ ?~L-P%QCIQZ
Name: (owner) ~1ow Ez~w>xzo5 SUBDIVISION LOT # a~
System Installer: C?c, s S-s n ~c Lt~„fl Registration #
Basement with plumbing: ❑ Garage X Number of Bedrooms 3
Type of Water Supply: ❑ Community ~X Public ❑ Well Distance from well T V~) feet
System Type: 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.
mis system has been installed in compliance 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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PERMIT (ONnITInN(-
L Performance:
II. Monitoring.
III. Maintenance:
IV. Operation:
V. Other.
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 N
If yes, see attached sheet for additional operation conditions, maintenance and reporting
❑ D-Box ❑ Pump ❑ Alarm ❑ 1-1201-ine ❑
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional Other Z G'L ow Septic Tank: \4 C) C) gallons Pump Tank:
Subsurface No. of exact length width of depth of
Drainage Field ditches ~ of each ditch I 0 feet ditches 3 feet ditches S~'a4
French Drain Reauired: .,"faAt
PWR Line
gallons
inches
Authorized State Agent tLL`~~ Date 'Al 13110
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