OPNTE#11-15--9Z IV- Harnett County Department of Public Health 24971
PERMIT # °S �SLtI enation Permit
New Installation eptic Tank 2-1rtr�ion Line ❑ Repair ❑ Expansion
Fled c�Sce PROPERTY LOCATION: IBO � me AmM Lo. C „M;e,�crt;-1 oA. sa—t
Name: (owner) Ta 1=�,em5 L—t..C_ SUBDIVISION LOT #
System Installer: oto :-c51loc— Registration #
Basement with plumbing: ❑ Garage ❑ yNN mber of Bedrooms t� _ Q<X-1 ('m W" Vs' Qj KT5cc`�Z
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Type of Water Supply: ❑ Community G4ublic ❑ Well Distance from well L�IA. feet db�'.�:n�r M!u(
System Type: C.onVp_gUaticLl G.erLsX\fS�t"en Types V and VI Systems expire in S years.
(In accordance with Table V a) � J Owner must contact Health Department 6 months prior to expiration for permit renewal.
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I. Performance: System shall perform in accordance with Rule .1961.
11. Monitoring: As required by Rule .1961.
111. 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 ❑
Following are the _sppeciflions for the sewage disposal system on the above captioned property.
Type of system: E, Conventional 9 Other
Subsurface No. of ? exact length �j �`
Drainage Field ditches 3 of each ditch _ 80 feet
H20Line ❑
'ro l'2opr�siij
-4- s -4a 63�
PWR Line
Septic Tank %Q:: P gallons Pump Tank: gallons
width of depth of
ditches feet ditches e2O aches
French Drain Required: Linear feet
Authorized State Agent Date GS IIS 190IR
Notice to Homeowner Declaring Exemption from Article 5 Chapter 90A
#p/1'N(Il Environmental Health Department has received
C
notification thatCounF , ,/ y /� �2 f��r,shall be declaring the exemption
Homeowner
as Homeowner under N.C. General Statute 90A -72(b)(2) to install and/or repair an on-site wastewater system.
In order to protect the environment, the Environmental Health Department advises if Homeowner does not have
prior experience in on-site installation and/or repair that a person certified by the North Carolina On -Site
Wastewater Contractors Inspectors Certification Board (NCOWCICB) be hired to do this service. Please be
advised that Environmental Health Department reserves the right to be present for any and/or all parts of the
installation and/or repair process including excavation and cover-up.
In order to declare the exemption all of the following requirements must be met:
Cystem must be a single septic tank
ystem must be gravity fed
�ystem must have gravel trench dispersal media
erson listed as Homeowner must own property
Property must be intended solely for use by Homeowner
and members of homeowner's immediate family who reside
[✓n the same dwelling
Homeowner shall perform installation and/or repair labor
without any monetary exchange or other means of payment for labor to any party other than a person
certified by NCOWCICB
By signing b0elow, the Homeowner hereby acknowledges the above statement.
Date
Homeowner Si tur7�
_ FIoN�7 �t, lo^'
Printer d
Name
STATE OF AlMk ea r01lno�
COUNTY OF 4 f tn-24A
I 1�ei Sc t c5 dot vyt �C a the undersigned Notary Public, do hereby certify that
1 . . .. C . personally appeared before me this day and acknowledged
.
the due en tKttOfft aforegoing instrument. ,
due
, notarial seal, this the /D day of Y�20�.
E y`: A (SEA ; v Notary Public
My C`gtl%hiss(d�
CC: File "',
LEHD