OPHTE# -3 -G :')l Harnett County Department of Public Health
PERMIT # 5 Q3 Operation Permit
New Installation X Septic TankX Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: `Vi NGG
Name: (owner) i L-L. ( RsL-4- 0m&5 SUBDIVISION 9sam o a1 LOT #
System Installer: \I4 -�tNr 0 A Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms 3
Type of Water Supply: ❑ Community Public ❑ Well Distance from well 1 O C3 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.
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
PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
H. 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 -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the ewage disposal system on the above captionekroperty.
Type of system: ❑ Con ' nal Other rLVA �rt1 Ga_ is u Septic Tank: 6aC?O gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 1 feet ditches feet ditches inches
French Drain Required:® ` tNt-
Authorized State Agent ����`•�� °'his Date 12
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PERMIT CONDITIONS:
I. Performance: System shall perform in accordance with Rule .1961.
H. 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 -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
Following are the specifications for the ewage disposal system on the above captionekroperty.
Type of system: ❑ Con ' nal Other rLVA �rt1 Ga_ is u Septic Tank: 6aC?O gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 1 feet ditches feet ditches inches
French Drain Required:® ` tNt-
Authorized State Agent ����`•�� °'his Date 12
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