OP RHTE# -6-y 2 Harnett County Department of Public Health 24929
PERMIT # Perm
NeL2' w Installation Septic TankNp itrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 2W Ajg4 Pow mal 4��2d S2/1/xi
Name: (owner)1 r SUBDIVISION LOT # $1
System Installer. Registration #
Basement with plumbing: ❑ Garage G IuMbwvf Bedrooms .3
Type of Water Supply: ❑ CommunityuLsI�P blit L7 Well Distance from well --1A feet
System Type: 23-6`Q Types V and VI Systems expire in S years.
(In accordance with Table V a) Owner contact Health Department 6 months prior to expiration for permit renewal.
I. Performance: System shall perform in accordance with Rule .1961.
II. 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:
V. Other.
❑
D -Boz
❑ Pump ❑ --
Alarm ❑ H2OLine
❑ PWR Line
Following are the
specifications for
the sewage system on the above ca tiop ned property.
Type of system:
❑ Conventional
Other G� f to��1. t�
Septic Tank , r cXr gallons
Pump Tank: gallons
Subsurface
No. of
exact length
width of
depth of
Drainage Field
ditches
of each ditch CmU feet
ditches 3 feet
ditches AE -3 inches
French Drain Retained:
Linear feet
Authorized State AgentDate e -N3
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