OPHTE# 1d- Harnett County Department of Public Health
PERMIT # Operation Permit 21 5 5 Q
)KI New Installation X Septic Tank Nitrification line ❑ Repair ❑ Expansion
PROPERTY LOCATION: Pe-4 )'~-sl~s ono , z
Name: owner # -L
SUBDIVISION C O LOT
System Installer. '~_q ~w j Registration #
Basement with plumbing. ❑ Garage Number of Bedrooms H
Type of Water Supply: ❑ Community ) Public ❑ Well Distance from well feet
System Type_ c. 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.
lms 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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I. Performance: System shall perform in accordance with Rule .1961.
11. 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 disposa system on the abov captioned pro
Type of system: ❑ Conventional Other ~J`' t^ Septic Tank: V C Q) gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches T of each ditch feet ditches 3 feet ditches inches
French Drain Required: _ Linear feet
Authorized State Agent Date
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