OPHTE# f b-5-3BHarnett County Department of Public Health 24206
PERMIT# —/ Operation Permit /
L' New Installatioc Tank (]/Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATIWN xx>-F,:� do..
Name: (owner) SUBDIVISION LOT # Z
System Installer: Registration #
Basement with plumbing: ❑ Garage ❑ umber of Bedrooms
Type of Water Supply: ❑ Community W Public ❑ Well Distance from well feet
System Type: 2-51.0--�e = Z% h�24�A ( 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.
Ibis system has been installed in compliance with applicable Rorth carolma 4eneral Statutes, Rules lot lewage treatment and Disposal, and all conditions of the Improvement Permit and construction Amhonzanon.
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I. Performance:
11. 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 ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewa$4 disposal system on the above captioned property.
Type of system: ❑ Conventional fY Other2i'� Septic Tank: /00 O gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches 3 of each ditch CD feet ditches 3 feet ditches Z i inches
French Drain Required: Linear Feet
Authorized State A ice' �ti�a— 4� Date
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