OPHTE# & -S-a Harnett County Department of Public Health
PERMIT # Operation Permit 21 5 5 4
New Installation E~ Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: .ic tt.ly ef
Name: (owner) ~r~«rsj~ W SUBDIVISION L-k-A Jam-/- LOT # r'
System Installer: 4 1 k1 C c, c Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms
Type of Water Supply: ❑ Community ❑ Public Well Distance from well 1610- feet
System Type: b 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.
pane a~ ueen uuwiea m compuance wIm appucaDie north larolma General Statutes, Rules for kwage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authonzaden.
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DCDMIT rA11NTln~lr.
L Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As required by Rule .1961.
111. 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 sp tfications for the sewage disposal system on the above captioned property.
Type of system: Conventional ❑ Other Septic Tank: gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches - of each ditch ~U feet ditches feet ditches J( inrhn<
French Drain Required: /.;7
' Linear feet
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Authorized State Agent / E ` Date Ca 141-41e)
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