OPHTE# Harnett County Department of Public Health 24928
PERMIT # lClci Operation Permq—
New Installation Septic Tank U itrirication Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: "I 6 .c- c, -,-z < s2 tas3)
Name: (owner) SUBDIVISION LOT #
System Installer. t_Gr _ Registration #
Basement with plumbing: Elarage ❑ Number of�Bedrooms
Type of Water Supply: E3 Community El Public elLi�W I Distance from well 1 00+ feet UgrolN
System Type: ;?Syo 'I,'. ', Lt S s - Types V and A Systems expire in S years. J
(In accordance with Table V a) Owner mus tact Health Department 6 months prior to expiration for permit renewal.
This system has been installed in compliance with applicable North Carolina General Smtutec, Rules for Sewage Treatment and RisposaL and all conditions of the Immurement Permit and
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PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
IL Monitoring: As required by Rule .1961. S ti tat 3
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:
V. Other.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage di pe�I s]stem on the above captioned roperty.
Type of system: ❑ Conventional l�bther C1 z"%liuSeptic Tank:ICS gallons Pump Tank gallons
Subsurface No. of exact length width of depth of
Drainage field ditches 3 of each ditch 'TUU feet ditches J feet ditches cR inches
French grain Required: Linear feet
Authorized State Agent Date c+3 I 1 atm
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PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
IL Monitoring: As required by Rule .1961. S ti tat 3
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:
V. Other.
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage di pe�I s]stem on the above captioned roperty.
Type of system: ❑ Conventional l�bther C1 z"%liuSeptic Tank:ICS gallons Pump Tank gallons
Subsurface No. of exact length width of depth of
Drainage field ditches 3 of each ditch 'TUU feet ditches J feet ditches cR inches
French grain Required: Linear feet
Authorized State Agent Date c+3 I 1 atm
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