OPH T E # ► 3 Harnett County Department of Public Health
PERMIT # ra~=►~► Operation Permit 21 8 5 3
New Installation X Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: ~C-Qcst c ~~r~
Name: (owner) ot~ y~~ ~v` •i~-~ s~ SUBDIVISION S v to mEt rt t ~t LOT #
System Installer: -Tj_NprUN q ,4 E, Registration #
Basement with plumbing: ❑ Garage 4 Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 'C)Qj feet
System Type: r31l b 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.
tnis system nas peen instauea in compuance wim appocame north Lamina ueneras xatutes, nines mr sewage treatment ana uisposat, ana au conamons of the
rermt ana construction nutnonzauon.
PERMIT CONDITIONS:
1. 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)101°
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 the specifications for the s a dispos
ewa
al system on the above captioned property.
Type of system:
El Conven
tional Other
E- 'Z- Septic Tank: 100 0
gallons Pump Tank: gallons
Subsurface
No. of
exact length width of
depth of
Drainage Field
ditches
of each ditch feet ditches
feet ditches N- inches
French Drain Required: - Linear feet
Authorized State Agent = S Date a? 1
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