OPHTE# Og-s-aoa. Harnett County Department of Public Health 2 0 5 5 4
PERMIT # a~5~3~- ~peratl0ti Perf111t
New Installation ~K Septic Tank ❑ Repairk Nitrification Line ❑ Expansion
PROPERTY LOCATION: Ccxt.Pwo,, e-Q
Name: (owner) ~S;hn ct_L ~t S SUBDIVISION CJti.%LL CU 4S LOT # a
System Installer. M ~xE Q.y Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms `a
Type of Water Supply: ❑ Community ❑ Public X, Well Distance from well feet
System Type: Tb 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.
I. Performance
II. 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 ❑ NoK,
If yes, see attached sheet for additional operation conditions, maintenance and reporting
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: X Conventional ❑ Other
Subsurface No. of exact length
Drainage Field ditches Lt of each ditch 50 feet
French Drain Reauired: r faor
Septic Tank: 100 O gallons Pump Tank: _
width of depth of
ditches 3 feet ditches aO
gallons
inches
Authorized State Agent Date
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