OP RRHTE#CCRHarnett County Department of Public Health 21 4 4 8
PERMIT # U eratlon Permit
New Installation Septic Tank ❑ Repair,.l Nitrification Line ❑ Expansion
_ PROPERTY LOCATION: Gac~sy ~>✓C Goa
Name: (owner) e2opEn ~~E~ SUBDIVISION - J>i LOT # 1
System Installer. ~nr fl ~~z rt,\ c--A Registration #
Basement with plumbing: ❑ Garage '9,, Number of Bedrooms _~j
Type of Water Supply: ❑ Community 'k Public ❑ Well Distance from well 160
feet
System Type: 1 a, 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.
.nu ,pam ❑a ueen imrauea to compliance with
North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the
Permit and Construction Authorization.
PERMIT r nITInv-
L, 1(),
I. Performance: System shall perform in accordance with Rule .1961.
II. 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:
Y. Other.
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional Other E~ Z- FLT Septic Tank: 1,000 gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches _ of each ditch °l0 feet ditches .3 feet ditches ILL inches
French Drain Required: l feet
Authorized State Agent J" - Q 0,,-5 Date 5113110
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