OP RRHTE#- '7 1,7/?- 4 Harne« County Department of Public hcalth
PERMIT # "7~.S-- Operation Permit 2 21 9 7
New Installation 9-Septic Tank C-Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: C-y ry rc~ >ec1.
Name: (owner) SUBDIVISION Cv ll LOT # ~7_
System Installer: ~~son /"I Registration #
Basement with plumbing: ❑ Garage 5Z- Number of Bedrooms 4
Type of Water Supply: ❑ Community Q"Public ❑ Well Distance from well feet
System Type: T1C 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 Permit and Construction Authorization
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1. Performance: System shall perform in accordance with Rule .1961.
11. Monitoring: As required by Rule .1961.
Ill. 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 ❑
Following are the specifications for the sewa disposa~ysystem on the above captioned property.
Type of system: ❑ Conventional Other ("J~-e~-
Subsurface No. of exact length
Drainage Field ditches of each ditch G 0 feet
French Drain Reauired: t
Authorized State
Alarm ❑ H20Line ❑ PWR Line
_ Septic Tank: 10"70 gallons Pump Tank: /000 gallons
width of depth of
ditches 3 feet ditches inches
Date 5 {'A I19~1
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