OPHTE# Harnett County Department of Public Health
PERMIT # Operation Permit 21 9 0 9
Eq New Installation ~K Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: Pa~oLOSta 'L
Name: (owner) ~c sow tL~ U. Co -A-:57 . SUBDIVISION CO,,a..o L '~~Z 45 LOT # y 1-3
System Installer: ^Tt-Q R)o--Uw N Registration #
Basement with plumbing: ❑ Garage ~K Number of Bedrooms 3
Type of Water Supply: ❑ Community -~R, Public ❑ Well Distance from well 10 O feet
System Type: 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
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1. Performance:
11. Monitoring:
III. Maintenance:
IV. Operation:
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ NoX
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
V. Other: 4'vr,)? Q+4,e,2~n 5"' ~1_,__r)0 JG. Cjs1~c„GG4> C:r' 3 q N
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional ~ Other t-) Septic Tank: MQ0 3 gallons Pump Tank: X000 gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 'Z,0 Q) feet ditches feet ditches }Z inches
French Drain Required: Linea
Authorized State Agent Date 3 I
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