OPHTE# r-4 - 6 -41444 Harnett County Department of Public Health 24161
PERMIT # 9 3 %% erasion Permit
New Installation E?Iii'ptic Tank tion Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 1155 4v,p P..d o-. (I Lc Jt �- �t
Name: (owner) L,� rsc, Conslr vk or. Trc-- SUBDIVISION � LOT # V(,
System Installer: —r -t, Ps ,, Registration #
Basement with plumbing: ❑ Garage Bedrooms
Type of Water Supply: ❑ Community L -Public ❑ Well Distance from well feet
System Type: 5' s Types V and VI Systems expire in S years.
(In accordance with Table V a) er must contact Health Department 6 months prior to expiration for permit renewal.
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I. Performance: System shall perform in accordance with Rule .1961.
If. Monitoring As required by Rule .1961.
111. 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 -Boz ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage"d'spesal system on the above captioned pro e
Type of system: ❑ Conventional 0/bther r r f ora Septic Tank I a 56 gallons Pump Tank gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches 3 of each ditch S 3 S feet ditches 3 feet ditches inches
French Drain Required: Linear feet
Authorized State Agent C _�� �� Date oa as I;? y
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