OP RRHTE# i0-5 2.~~~~~LC2 Harnett County Department of Public Health
PERMIT #a~ d Operation Permit 21 8 6 2
New Installation ❑ Septic Tank ❑ Nitrification Line ❑ Repair ❑ Expansior
PROPERTY LOCATION: NS~a10
Name: (owner) Gacoy SUBDIVISION Q, EN ~e~KS LOT # ~5_
System Installer: QN ,s J° s2 lCXrI AN Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms 3
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 143 0 feet
System Type: 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.
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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1. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ Nol°'t
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D-Box ❑ Pump ❑ Alarm ❑ 1-1201-ine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional IR Other _&L 'P-,-ow Septic Tank: 1!Z) 00 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches -of each ditch CL:-) O feet ditches - feet ditches inches
French Drain Reauired: \ Lin`12r..feet\\
Authorized State Agent 'k,,, 4\-~5 Date