OPHTE# Harnett County Department of Public Health
PERMIT # Operation Permit 2 21 01
New Installation V Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: MArz~..~
Name: (owner) Vr~ tt,A~~ o SUBDIVISION INS')'r-_-'F0a x> LOT # 3-5
System Installer: I r-- o 16 ag -,,4 r4 Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms `l
Type of Water Supply: ❑ Community 1 Public ❑ Well Distance from well t ®a feet
System Type: - tr. 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 Perm' and Construction Authorization
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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 ❑ N
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewage disposal ~sYstem on the above f a tione roperty.
Type of system: ❑ Conventional Other r-~3FQ 1.RI~k Septic Tank: )QQQ gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage field ditches of each ditch 0 feet ditches feet ditches o1 inches
French Drain Reauired: _ 6u feet -
Authorized State Agent Date ~ { 1
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