OPHTE# 11- s _ 41497 Harnett County Department of Public Health 24859
PERMIT # Qcl66 - Ou satfon Permit
2'l—ew Installation �c Tank i Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 11(z nom, S, isia,r„k ¢1, s2avaj)
Name: (owner) W.,rsct Gons4r—x—(Con S SUBDIVISION Ajmer 4'Oe,.,4� LOT # 5L
System Installer. C''1' i Registration #
Basement with plumbing: El Garage Number of Bedrooms �%
Type of Water Supply: ❑Community �c ❑ Well Dista from well feet
System Type: i'Zu /Lem « f ,r A —2!1_ s Types V and VI Systems expire in S years.
(In accordance with Table V a) Ow r must contact Health Department 6 months prior to expiration for permit renewal.
[his system has been installed in mmpliano 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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PERMIT CONDITIONS
I. Performance: System shall perform in accordance with Rule .1961.
Il. 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:
V. Other.
❑ D -Box ❑ Pump ❑ Alarm ❑ HZOLine ❑ PWR Line
following are the specifications for the sewage disposal system on the above captioned probe .
Type of system: ❑ Conventional 9- ther Septic Tank: la 50 gallons Pump Tank: gallons
Subsurface No. of exactlength width of depth of �y�
Drainage Field ditches' of each ditch feet ditches _ feet ditches inches
French Drain Required: Linear feet
Authorized State Agent Date
8