OPHTE# 17-5-Q31 Harnett County Department of Public Health 24717
PERMIT #Zq 'MS Operation Permit
New Installation tic Tank 9 --Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: tete M.1lly as 2?. C-5 rJ3e)
Name: (owner) t>a< , ; ti L. rn oca J SUBDIVISION LOT # a4
System Installer: Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms OV—
Type of Water Supply: ❑ Community blit ❑ Well Distance from well feet
System Type: 'Z5Y n...d...k,: ,. s—Tries' 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.
mit system nas been Installed in compliance with applicable North (mlina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Impmvement Permit and Construction Authorization.
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PERMIT CONDITIONS
1. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
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.
V. Other:
❑
D -Box ❑
Pump ❑
Alarm ❑
H2OLine ❑ PWR Line
Following are the
specifications for the sewage disposal
system on the above captioned
property.
Type of system:
❑ Conventional 9 -15i her
Q I L4—ick,
Septic Tank: iyax--
gallons Pump Tank gallons
Subsurface
No. of
exact length
width of
depth of
Drainage Field
ditches
of each ditch 9c�
feet ditches 3
feet ditches inches
trench Uram Required: Linear feet
Authorized State Agent _ Date 10 / a'6/aoFj—
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