OPNTE# LG- s - 3 9JI� Harnett County Department of Public Health 24412
PERMIT # Z5 D/ I CiDmtion Permit
[9-1ew Installation CISeptisc Tank I✓"itrification Line ❑ Repair El Expansion
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PROPERTY LOCATION: 4 Ac,,7oso.s 2J, . (-5 rL Z ca 3 C )
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Name: (owner) YLo 'e -t &,c, el SUBDIVISION LOT#
System Installer. QZZ,s cS c/G: -A Registration #
Basement with plumbing: ❑ Garage � NuE °sof Bedrooms
Type of Water Supply: ❑ Community vublic ❑ Well Distance from well feet
System Type: % : - f Types V and VI Systems expire in S years.
(In accordance with Table V a) Owner mulieclontact 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.
If. Monitoring. As required by Rule .1961.
III. 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 ❑ H2O1-ine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned roe
Type of system: El Conventional �r F'L c -.a Septic Tank: gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches 3 of each ditch 95 feet ditches 3 feet ditches inches
French Drain Required: Linear feet
Authorized State Agent�.-���_� ��r� Date °G�o6�20
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