OPHTE# 11-5 -UIyoS Harnett County Department of Public Health 24135
PERMIT # a `1;?QC 0 ation Permit
New Installation et�S ptic TankICrI I a n Line ❑ Repair [I Expansion
PROPERTY LO(ATION: 'M5 Pow IDr. (LM.I)1�-,le sa. ixl?n)
Name: (owner) >aMn^semx ti3 c SUBDIVISION ALOT # s�
System Installer: Registration #
Basement with plumbing: ❑ Garage I�er drooms
Type of Water Supply: ❑ Community ubLzYY lic Ll Well Distance from well —A, feet
System Type: 3` rh.o S Types V and VI Systems expire in S years.
(In accordance with Table V a) wner must contact Health Department 6 months prior to expiration for permit renewal.
anis system ha been installed to compliance with applicable North Carolina General Statures, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construmon Authorization.
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PERMIT CONDITIONS
I. Performance:
If. Monitoring:
III. Maintenance:
IV. Operation:
V. Other.
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 Cal/
If yes, see attached sheet for additional operation conditions, maintenance and reporting
❑ D -Box ❑ Pump ❑ Alarm ❑
H2O1.ine ❑
Following are the specifications for the sewage disposalsystem on the above captiroperty.
Type of system: El Conventional I�r �: _Lo.a sN � Septic Tank gallons Pump Tank
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch /Ou feet ditches — feet ditches
french Drain Required: Linear feet
Authorized State Agent Date 0l IG I qol�)
PWR Line
gallons
inches
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