OP RHTE# Harnett County Department of Public Health 24930
PERMIT # lad{, 0 Mion Perm'
ew Installation Septic TankNip' trifiication Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:_
Name: (owner)n Cn a ren Tn SUBDIVISION Awe
System InstallerRegistration #
Basement with plumbing: ❑ Garage N lU54�"edrooms
Type of Water Supply: ❑ Community -public E-1WellDist m well t---> A het
System Type: 5�� (Ln LI c { �� ��s�n 1 Types V and VI S
(In accordance with Table V a) Ow,,4ust contact Health De ent 6
This system has been installed in compliance with applicable North Carolina General Statutes, Rules hr Se reammnt and Disposal, and all
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1. 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.
' 4r
e in S years.
prior to expiration for permit renewal.
Of the lmnr0eement Permit and
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� C '0 � Llt�;' f3 I--,
cek t.t� tnd,
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage dustal system on the above captioned ro e
Type of system: ❑ Conventional ter �� t_ n _I , Septic Tank: gallons Pump Tank gallons
Subsurface No. of exact length `� width of depth of
Drainage Field ditches of each ditch v0 feet ditches 3 feet ditches f inches
French Drain Required: Linear feet
Authorized State Agent Date