OPHTE # LI 5-41J(„tf Harnett County Department of Public Health 24169
PERMIT # a7� si 0 enation Permit
lew Installation 2feptic TankNit trification Line ❑ Repair ❑ Expansion
—{� PCko ce�C PROPERTY LOCATION: L5rt, t53_5�
Name: (owner) SUBDIVISION LOT #
System Installer: PcA G� e4 Registration #
Basement with plumbing: ❑ Garage umber Bedrooms _
Type of Water Supply: ❑ Community Ic ❑ Well Distance from well feet
System Type: S Types V and VI Systems expire in S years.
(In accordance with Table V a) Ow must contact Health Department 6 months prior to expiration for permit renewal.
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PERMIT CONDITIONS:
reatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization.
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I. Performance:
System shall perform in accordance with Rule .1961.
11. 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:
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V. Other:
❑ D -Box ❑ Pump ❑ Alarm ❑ H2O1-ine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional 9-;(5d1er P'u Is t��_ Septic Tank: I �'�� gallons Pump Tank gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches S of each ditch -40 feet ditches 3 feet ditches / 8 inches
french Drain Required: Linear feet
Authorized State Agent Date