OPHTE# ;Y. °� �� Harnett County Department of Public Health
PERMIT # z_7 Z Operation Permit 22495
E New Installation E Septic Tank F,/1 Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: 'LiS q -:2_)
Name: (owner) t SUBDIVISION LOT #
System Installer: A, c, I ,- Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms .3
Type of Water Supply: ❑ Community Q Public ❑ Well Distance from well ` ` �� —.__ feet
System Type: a`'v t " ' °' r, ` t° "� " —ypes V and VI Systems ' S years.
(In accordance with Table V a) Owner m� contact Health Department 6 months prior to ex ' 6on for permit renewal.
This system has been installed in camoliance with aoolicable North Carolina General Statutes. Rules for Sewage Treatment and Disaosal. and all conditions of the
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PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
ll. 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:
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Permit and Construction
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: El Conventional 2FOther Septic Tank: gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 0 feet ditches feet ditches inches
French Drain Required: Linear feet
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Authorized State Agent; -- Date 15 ` 1