OPHTE# -s=a8IkI Harnett County Department of Public Health
PERMIT # t~ f OperationPermit 2 21 71
I' New Installation V Septic Tank ❑ Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: C ~.l .~11 ~~~cl
Name: (owner) x;11', SUBDIVISION LOT #
System Installer: C)+-~ '.r J fir. c k 1c" Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms -3
Type of Water Supply: ❑ Community D"'Public ❑ Well Distance from well feet
System Type: c?, } 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.
❑us system nas ueen mszanea in
Permit and Construction Authorization.
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1. Performance:
Il. Monitoring:
III. Maintenance:
IV. Operation:
V. Other:
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ No 0
If yes, see attached sheet for additional operation conditions, maintenance and reporting
❑ D-Box ❑ Pump ❑
Following are the spef'fications for the sewage disposal system on the above captioned property.
Type of system: 2 Conventional ❑ Other
Subsurface No. of exact length
Drainage Field ditches ~XJ r of each ditch feet
PWR Line
Septic Tank: /000 gallons Pump Tank: gallons
width of depth of
ditches feet ditches inches
0:_ Date 2 wan applicable norm Larmma beneral Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the
french Drain Required: Linear feet
Authorized State Agent//5"'
Alarm ❑ H20Line ❑
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