OPHTE# 11-S-y�sG Harnett County Department of Public Health 24857
PERMIT # OELeration Permit
&'New Installation L'Septic Tank 0-- ifnfication Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: aISd RAE•:3 n -A SrL 1131)
Name: (owner)SUBDIVISION LOT #
System Installer: H endt-mc) Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms
Type of Water Supply: ❑ Community ublic ❑ Well Distance from well ^ 4- feet
System Type: 26,%, 4 — o n su sner Types V and VI Systems expire in 5 years.
(In accordance with Table V a) wmust contact Health Department 6 months prior to expiation for permit renewal.
I. 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 ❑ No
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
Other:
❑
D -Box ❑
Pump ❑ Alarm ❑
H201-ine ❑ PWR Line
Following are the
specifications for the sewwage�dis oral
system on the above captioned property.
Type of system:
El Conventional f�'Other
rj5-�-, r -7o Septic Tank: iCx+s
gallons Pump Tank: gallons
Subsurface
No. of
exact length width of
depth of
Drainage Field
ditches 3
of each ditch %O feet ditches 3
feet ditches inches
French Drain Required: Linear feet
Authorized State Agent 4 Date la`11 aT01�