OPHTE# , r--r5-r Z0Z Harnett County Department of Public Health
PERMIT # Operation Permit 21 7 4 5
❑ New Installation ❑ Septic Tank ❑ Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION,,W, / a-P' r
Name: (owner) SUBDIVISION 4. CZ c > _ LOT # 3
System Installer: z~Registration #
Basement with plumbing: ❑ Garage ❑ umber of Bedrooms
Type of Water Supply: ❑ Community Ef Public Well Distance from well feet
System Type: ' Types V and VI Systems expire in 5 years.
(In accordance with Table V a) 4 t Owner must c ntact Health Department 6 months prior to expiration for permit renewal.
lms system has been installed in complumce with applicable North larolina hegeral Statutes, Rules tar Sewage Ireatment and Disposal, and all conditions at the
i
/ 03
1-202
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Permit and Construction Authorization.
rtKMII t,unulltuwi:
1. 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 ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D- ox Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following a e the F ations for the sewT disposal system on the above captioned property.
Type of sy tem: nventional Septic Tank: gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of r r
Drainage F~d ditches of each ditch feet ditches 3 feet ditches inches
French Drain ~Re uired: Linear feet
Authorized State Agee-rte, Date 7-1(a-12