OPHTE# ) j - s - 4+aati5 Harnett County Department of Public Health 2 41 6 7
PERMIT # a 4 a4p 0 - ration Perm'
Jew Installation ETIeptic Tank EI Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: SS ra jj it 5 L (43c cdG M' 11 Ra . SCZ.?QL6
Name: (owner) L��,�ix�na �10 e5 LL.0 SUBDIVISION C �Qs1� c LOT #
System Installer: n Registration #
Basement with plumbing: ❑ Garage umber of Bedrooms
Type of Water Supply: ❑ Community ❑ Public ❑ Well Distance from well feet
System Type: S 5 . —=i Types V and VI Systems expire in S years.
(In accordance with Table V a) Owner mu contact Health Department 6 months prior to expiration for permit renewal.
this system has been installed in cumplianre 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:
H. 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 D'
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
❑ D -Box ❑ Pump ❑ Alarm ❑
H2OLine ❑
Following are the specifications for the seewwage�d dual system on the above captioned jr e�
Type of system: ❑ Conventional LYOther tC 11, rL(:> Septic Tank: S C:: X gallons Pump Tank:
Subsurface No. of exact length ter— width of depth of
Drainage Field ditches of each ditch —)L feet ditches 3 feet ditches
French Drain Required: Linear feet
Authorized State Agent � Date 0 3 I U-4 1 ;?o
Line
gallons
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