OPHTE#1(e-S-'�o48� Harnett County Department of Public Health
24133
PERMIT # Z 5 �6� ration Permit
2 New Installation eptic Tank cation Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:—
Name:
OCATION:—Name: (owner) _Torn rani Z S le a . h SUBDIVISION
LOT #
System Installer. yv s Registration #
Basement with plumbing: ❑ arage ❑ Number of Bedrooms .3
Type of Water Supply: ❑ Community ❑ Public C+3'Well Distance from well 99-5 feet
System Type: 2526 n,Avc4, r, -1iS;Z Types V and VI Systems expire in S years.
(In accordance with Table V a) r Owner must contact Health Department 6 months prior to expiration for permit renewal.
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PERMIT
Treatment and Disposal, and all conditions of the Improvement Permit and
Authorization.
— I
I. 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 rfa"
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage ' posal system on the above captioned property.
Type of system: El Conventional Other 25% Q4.,I F+un C- Septic Tank gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches I of each ditch Z U feet ditches fept ditrhn< IR ;.•,h,.
-- ------ - ........
rent rain Required: Linear feet
Authorized State Agent Date a 1 /5' 7
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I. 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 rfa"
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage ' posal system on the above captioned property.
Type of system: El Conventional Other 25% Q4.,I F+un C- Septic Tank gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches I of each ditch Z U feet ditches fept ditrhn< IR ;.•,h,.
-- ------ - ........
rent rain Required: Linear feet
Authorized State Agent Date a 1 /5' 7
. 2�fis=s
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