OP RHTE# /0-Z X-0?6/f- Harnett County Department of Public Health
PERMIT # / Operation Permit 21 81 2
CT New Installationonc Tank VNitriffcation Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: A I(,- 4-
Name: (owner) c5 e 1,t Qr, SUBDIVISION LOT # .7.7
System Installer: G C_./' tzc~c /tee c Registration #
Basement with plumbing: ❑ Garage L umber of Bedrooms 7
Type of Water Supply: ❑ Community ublic ❑ Well Distance from well feet
System Type: q- Types V and VI Systems expire in 5 years.
(In accordance with Table V a) Owner must contact Health Department 6 months prior to expiration for permit renewal.
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization
rtnPnl t.UNUIIIUNJ:
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;
T
1- 2
❑
D-Box
❑ Pump ❑ Alarm
❑ H20Line ❑ PWR Line
Following are the specifications for
Type of system: El Conventional
the sew
a disposal system on the =%--1 oned property.
Other ~ fit t
(jcs
Septic Tank: gallons Pump Tank: gallons
Subsurface
No. of
exact length _
width of depth of
Drainage Field
ditches
of each ditch feet
ditches - feet ditches' inches
French Drain Required: Linear feet
Authorized State Agen Date
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