OP RHTE# Harnett County Department of Public Health
PERMIT # 0l►eration Permit 21 6 4 6
New Installation X Septic Tank "'R Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 1, a 6E :~,c>
Name: (owner) W c.Ls" CJo,~S> a v cr, r n SUBDIVISION LOT
System Installer. L_A< -j S~la2P Registration #
Basement with plumbing. ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well ~ b O feet
System Type: --01 c9 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.
This 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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rtISPUI LUNUIIIUNN:
1. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring. As required by Rule .1961.
III. Maintenance: 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.
IV. Operation:
V. Other.
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned p erty.
Type of system: ❑ Conventional P, Other C. Rec~BEiL (r' k y Septic Tank: 100 b gallons Pump Tank: gallons
Subsurface No. f exact length width of depth of
Drainage Field ditches of each ditch S 0 eet ditches 3 feet ditches o1~1`)~ inches
French Drain Required ® as i Sr <'4 ~'-7/
Authorized State Agent N<~~ Date lO I V, I c-0
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