OPHTE# 11 -6 -LOO Harnett County Department of Public Health 24985
PERMIT # a�,a'� eration Perm' d
New Installation Se tic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: d5`� Lys, I ,nSn ( Sif ;t7A
Name: (owner) QeA max Nc, La SUBDIVISION LOT #:—
System Installer: PokrICA (IC dti,rr— Registration #
Basement with plumbing ❑ Garageu of Bedrooms
Type of Water Supply: ❑ CommunityEi'Public ❑ Well Distance fio II feet
System Type: 5c –4DZn5. Types V and VI Systems expire in S years.
(In accordance with Table Y a) rJ Owner must ontact Health Department 6 months prior to expiration for permit renewal.
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PERMIT
I. Performance: System shall perform in accordance with Rule .1961.
11. Monitoring: As required by Rule .1961. /
III. Maintenance: As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ NoAPK
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other.
of the Improvement Permit and (destruction
❑ D -Box ❑ Pump ❑ Alarm ❑ H20Line C PWR Line
Following are the specifications for the sewagesal system on the above captioned proper
Type of system: ElConventional l � 3 ( )n fir— �' Septic Tank: kg -,t ", gallons Pump Tank: gallons
Subsurface No. of exact length Ili width of depth of
Drainage Field ditches 3 of each ditch feet ditches,� _ feet ditches inches
trench Brain Required: Linear feet
Authorized State Agent / Date