OPHTE#10-Harnett County Department of Public Health
PERMIT # Operation Permit 21 7 9 5
, l New Installation )5 Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
Name: (owner) W j "sv C-~ r-6 ScL,c.;\ o f -4
System Installer: W,6a.: dr.% QL-- U mg\r-a c,
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well
System Type:G
(In accordance with Table V a)
PROPERTY LOCATION:\-lwy~)Q1yj
SUBDIVISION 1 +~1.~1 Po , USE LOT
Registration #
3
Distance from well 160 feet
Types V and VI Systems expire in 5 years.
Owner must contact Health Department 6 months prior to expiration for permit renewal.
Ims system nas been installed in compliance with applicable North larolma General Statutes, Rules for Sewage Ireatment and
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and all conditions of the Improvement Permit and Construction Authorization.
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1. 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 ❑ H201-ine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional X Other Septic Tank: \000 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch feet ditches 3 feet ditches inches
French Drain Reauired: _ , 'gear feet
Authorized State Agent \N~~\ q- k S_ Date I2.I aA1v