OPHTE# Harneft county Department of Public Hewth
PERMIT # Operation Permit 21 7 5 5
New Installation X1 Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOfATION: ~,A12E V-P
Name: (owner) LbC. ~N c, SUBDIVISION ~~iL p u F~ a r~5 LOT # _
System Installer: W R-1"~-- 5 Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well BOO 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.
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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I. Performance: System shall perform in accordance with Rule .1961.
11. 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 th
e specifications for
the sewage disposal system on the above captioned pro
Type of system:
El Conventional
Other C-.Y~, c,m4EU CM u, C.'e- ti)
Septic Tank: i O O O gallons Pump Tank: gallons
Subsurface
No. of
exact length
width of depth of
Drainage Field
ditches
of each ditch t d feet
ditches feet ditchesd inches
French Drain Required: A~ one , eet
Authorized State Agent Q ~a~5 10
Date is `1 ~
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