OPHTE# IL-5-4cRl5 Harnett County Department of Public Health 24724
PERMIT # a &4 6 Operation Permit
�( New Installation �'K Septic Tank '1< Nitrification Line ❑ Repair ❑ Expansion
y� PROPERTY LOCATION: Co - v
Name: (owner) �2sAavGGE �otnE { yps SUBDIVISION C.oxf se utLy Porz�. LOT #
System Installer: -'Zw-i �\DGOc.`� Registration #
Basement with plumbing: ❑ Garage)< Number of Bedrooms
Type of Water Supply: ❑ CommuniPublic EJWell Distance from well feet
System Type: �Atis Types V and V1 Systems expire in S years.
(In accordance with Table V a) Owner must contact Health Department 6 months prior to expiration for permit renewal.
Ibis system bas been Imtalled in compliance with applicable North Carolina Genegil Statutes. Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and construction Authorization
rLmrlu wnunsona:
I. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
V. Other.
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System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ No
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
❑ D -Box ❑ Pump ❑
0
H20Line ❑
PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional Other EZ Fl...ow Septic Tank: S OOO gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches 3 of each ditch �S feet ditches 3 feet ditches �T inches
French Drain Required: inear feet
Authorized State Agent Date B
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