OPHTE# Harnett County Department of Public Health
PERMIT # Q Operation Permit 21 6 5 4
'1?~- New Installation t3- Septic Tank 1~4 Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:
Name: (owner) L'~-V-Nn SUBDIVISION Cf~r~c2 ~r~ , ~,cs LOT #
System Installer: (1poA< Registration #
Basement with plumbing: ❑ 6ki4ge q Number of Bedrooms 3
Type of Water S ply: ❑ Community Public ❑ Well Distance from well feet
System Type: f> Q 'C k '4 c jT,8 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.
ims system nas peen mstaueo in compliance with
North Carolina General Statutes, Rules for Sewage Treatment and
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1 X111111 6VI~VIIIV I\J.
1. Performance:
11. Monitoring:
III. Maintenance:
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other:
IV. Operation:
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting
V. Other.
qt , 1;~-itA3 D-Box [ Pump ct Alarm H20 Line ❑ PWR Line
following are the specifications for the sewage dispos4Isystem on the above captioned property.
Type of system: ❑ Conventional Other q Aj C~ \ r~ Id)Septic Tank: 'DOO gallons Pump Tank: v gallons
Subsurface No. of exact length width of depth of
Drainage field ditches _ of each ditch ~O feet ditches- feet ditches 01 inches
French Drain Reauired-. ~ , J-,in t
and all conditions of the Improvement Permit and Construction Authorization.
I Authorized State Agent azA~S Date itA 10
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