OPHTE#— -Ao_ 4 Harnett County Department of Public Health 24166
PERMIT # 0aeration Pernu't-
12-
New Installation Septic TankNps itrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: q5 Go(kf o t w-,- ( "4k—' M d 5 t h
Name: (owner) Va� --so�ro uc,,,� y c,. SUBDIVISION LOT # _
System Installer: Registration #
Basement with plumbing: ❑ Garage tqpbff of Be ms _-3
Type of Water Supply: ❑ Community L�' Public ❑ Well Distance from well feet
System Type: c 5 s5 4e Z[Lr-- Types V and VI Systems expire in 5 years.
(In accordance with Table V a) 0 er must contact Health Department 6 months prior to expiration for permit renewal.
I. Performance:
II. 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 l7/
If yes, see attached sheet for additional operation conditions, maintenance and reporting
❑ D -Box ❑ Pump ❑ Alorm ❑
1112O1-ine ❑
Following are the
specifications for
the sewage dis osal system on the above captioned ro erly.
Type of system:
❑ Conventional
✓
ter �7
Septic Tank: 1000 gallons
Pump Tank
Subsurface
No. of
exact length
width of
depth of
Drainage Field
ditches
3 of each ditch ?—) U feet
ditches �_ feet
ditches 22
trench Brain Required: Linear feet
Authorized State Agent Date e !o Z 1 aUl P,
PWR Line
gallons
inches
ca