OPHTE# q -S -q2631 Harnett County Department of Public Health 24994
PERMIT # ��y� .9 eration Permi
NeW Installation Septic TankItrlfication Line ❑ Repair ❑ E
PROPERTY LOCATION: '3G4 Po weal T� CLA - C 5/L
Name: (owner) v( rm, ori Pc, sQ�S SUBDIVISION LOT #
System Installer: YL\k> 1—�,— Registration #
Basement with plumbing. ❑ Garage � Nof Bedrooms
Type of Water Supply: ❑Community PLtY ublic ❑ Well Distance from well S (30A feet
System Type: Gt6X3 aAA,,t-:cen 5 C4 Types V and VI Systems expire in 5 years.
(In accordance with Table V a) Ownel4ust contact Health Department 6 months prior to expiration for permit renewal.
This system has been installed in compliance with asoliable North Carolina
Rules for SewDrineawens and
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Permit and Construction Authorization.
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PERMIT CONDITIONS:
1. Performance: System shall perform in accordance with Rule .1961.
It. 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.
❑ D -Box ❑ Pump ❑ Alarm ❑ 142O1-ine ❑ PWR Line
Following are the specifications for the se�wage�sal s tem on the above captioned property.
Type of system: ElConventional ID, Other Septic Tank: I,CiC)J gallons Pump Tank: gallons
Subsurface No. of exact length��� width of depth of
Drainage Field ditches of each ditch ` r���� feet ditches feet ditches I inches
trench Dram Required: linear feet
Authorized State Agent Date O-4ladtS
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