IPAC REPAIRHTE# Harnett County Department of Public Health 27704
Imarovement Permit
A building permit cannot be issued with only an Improvement Permit
PROPERTY LOCATION:'Q f y Z 01,, rss , J 6,-J /Z/b
ISSUED T0: ��1BDIVISION LOT #
NEW ❑ REPAIR Rf EXPANSION ❑ Site Improvements required prior to Construction Authorization Issuance:
Type of Structure: �'x AW M 14
Proposed Wastewater System Type: OS-C1'6 'M�
Projected Daily Flow: a GPD
Number of bedrooms: Number of Occupants: _max
Basement ❑Yes No
Pump Required: ❑Yes ❑ No 1ae required bass on final location and elevations of facilities
Type of Water Supply: El Community LET Public 2' Well Distance from well feet Permit valid for: Q"Five years
Permit conditions: ❑ No expiration
Authorized State ent:: / r Date: 11— Z4_1 -Z' 3 SEE ATTACHED SITE SKETCH
The issuance of this permit by7&Aealth Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This
site is subject to revocation if the site plan, plat, or the intended use changes. The Improvement Permit shall not be affected by a change in ownership of the site. This permit is subject to compliance with the provisions of
the Laws and Rules for Sewage Treatment and Disposal and to conditions of this permit..
Construction Authorization
(Required for Building Permit)
The construction and installation requirements of Rules .1950, .1952, .1954, .1955, .1956, .1951, .1958. and .1959 are incorporated by references into this permit and shall be met. Systems shall be installed in accordance
with the attached system layout.
ISSUED TO: •Q+ifrrA PROPERTY LOCATION:5Yf /yjZt% %.tlsc7itlr� C "/J
SUBDIVISION LOT #
Facility Type: ❑ New ❑ Expansion Repair
Basement? ❑ Yes L3' No Basement Fixtures? ❑ Yes 3-CO
Type of Wastewater System"
(See note below, if applicable ❑)
LSD/ /2r�U CV(JIY')--� 5y/ 3' (Repair)
Installation Requirements /Conditions Number of trenches
Septic Tank Size / OD o gallons
Pump Tank Size gallons
Pump Requirements: ft. TDH vs.
Conditions:
Exact length of each trench / S y) feet
Trenches shall be installed on contour at a
Maximum Trench Depth of. Z�O "> 1'3 inches
(Trench bottoms shall be level to +/ -1/4"
in all directions)
GPM
(Initial) Wastewater Flow: 3C&n GPD
Trench Spacing: feet on Center
Soil Cover:nches
(Maximum soil cover shall not exceed
36" above the trench bottom)
Aggregate Depth:
WATER LINES (INCLUDING IRRIGATION) MUST BE LOFT. FROM ANY PART OF SEPTIC SYSTEM OR REPAIR AREA.
NO UTILITIES ALLOWED IN INITIAL OR REPAIR DRAIN FIELD AREA.
inches below pipe
2- inches above pipe
inches total
* *If applicable: /understand the system type specired is different from the type speciped on the app lication. / accept the speciflwiona of this permit.
Owner /Legal Representative Signature: Date:
This Construction Authorization is subject to revocation if the site plan, plat, or the intended use changes. The Construction Authorization shall not be transferred when there is a change in ownershio of the site. This
Construction Authorization is subject to compliance with the
Authorized State
of the Laws and Rules for Sewage Treatment and Disposal and to the conditions of this permit SEE ATTACHED SITE SKETCH
Date: tP - -1c, --13
Construction Authorization Expiration Date: i t 2- t 2—
HTE# Permit # Z;:77 --7
Harnett County Depailment of I'nblic Health
Site Sketch
PROPERTY LOCATON: 11 x,,,. jw
ISSUED T0: �,�,� %��,.��, J .;,,,, (% ,� SUBDIVISION J LOT #
Authorized State Agga -. Date: A—Z4 —13
4 /!
?� HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
307 W. CORNELIUS HARNETT BLVD.
LILLLNGTON, NC 27646
910 -893 -7647 PHONE
�/JG� �G�F,tok1 /i%ritli�Pf1% 910 -893 -9371 FAX
*es A�;7IC Appiication for repair
11f- 77A•� ®�3
4,,,,-EMAIL ADDRESS: /f 74/ L04ky/111
NAMECC /i/jfo/1�s /-B/Q L1l�f �jpp/(f iii PHONE NUMBER fig- ??/•7��„{G{I���
PHYSICAL
MAILING ADDRESS (IF DIFFFERENTTHANMYSICAL) ✓� d
IF RENTING, LEASING, ETC., LIST PROPERTY OWNER NAME
►Rl 11� N/2 -v0( A rli AA a °71 i fit` 07rel C �/5�►1� /_. ° /� Cy
SUBDIVISION NAME LOT R /TRACT it STATE RD /HWY SIZE OF LOT/TRACT
Type of Dwelling: [ I Modular ( Mobile Home [ ] Stick built ()Other,
Number of bedrooms _
Garage: Yes [ I No I4
Water Supply: [ I Private Well
Directions from Lillington WVol
( I Basement
Dishwasher, Yes M No [ I
[ I Community system 0 County
site: vr/ /3lm, --IL 1, jpl�-,Vd
Garbage Disposal: Yes [ I No It
In order for Environmental Health to help you with yourrepair, you will need to camp/yhy completing the fallowing:
1. A "sure ed and mrorded map" and "deed to your oroaerw must be attached to this application. Please inform us of any
wells on the property by showing on your survey map.
2. The outlet end of the tank and the distribution box will need to be uncovered and property lines flagged. After the tank is
uncovered, property lines flagged, underground utilities marked, and the orange sign has been placed, you will need to call
us at 910- 893 -7547 to confirm that y your site is Tear y r -evaluation.
Your system must be repaired within 30 days of Issuance of the Improvement Permit or the time set within receipt of a violation
letter. (Whichever Is applicable.)
By signing below, l certify that all of the above Information is correct to the best of my knowledge, False information will result in
the denial of the permit. The permit is subject to revocation if the site plan, Intended use, or ownership changes. S
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HOMEOWNER INTERVIEW FORM
It is important that you answer the following questions for our inspectors. Please do not leave any blanks if
possible, and answer all questions to the best of your ability. Thank You.
Have you received a violation letter for a failing system from our office? [ ] YES W NO
Also, within the last 5 years have you completed an application for repair for this site? [ ] YES QQ NO
AAmA-
Year home was built (or year of septic tank installation) 40/441 Ago
Installer of system v a
Septic Tank Pumper �&J.f dk, A/4
Designer of System
I. Number of people who live in house? .. _# adults _ # children # total
2. What is your average estimated daily water usage? gallons /month or day county
water. If HCPU please give the name the bill is listed in
3. If you have a garbage disposal, how often is it d? [ ] daily [ ] weekly [ ] monthly /f //f
4. When was the septic tank last pumped? t�How often do you have it pumped? /J 5f,
5, if you have a dishwasher, how often do you use it. (]daily [ ]every other day [ ]weekly W19
6. If you have a washing machine, how often do you use it? I ] dally ( I every other day ( ] weekly [ monthly
7. Do you have a water softener or treatment system? [ j YES DO NO Where does it drain?
S. Do you use an "in tank" toilet bowl sanitizer? [ ] YES DQ NO
9. Are you or any member in your household using long term prescription drugs, antibiotics or
chemotherapy ?] [ ] YES D(NO If yes please list
10. Do you put household cleaning chemicals down the drain? (] YES [x] NO If so, what kind?
11. Have you put any chemicals (paints, thinners, etc.) down the drain? [ ] YES [)[ NO
12. Have you installed any water fixtures since your system has been installed? [ ] YES Q(] NO If yes,
please list any additions including any spas, whirlpool, sinks, lavatories, bath /showers, toilets
13. Do you have an underground lawn watering system? [ ] YES J4 NO
14. Has any work been done to your structure since the initial move into your horpe such as, a roof, gutter
drains, basement foundation drains, landscaping, etc? If yes, please list AD
15. Are there any underground utilities on your lot? Please check all that apply:
[ ] Power [ ] Phone [ ] Cable [ ] Gas [ ] Water
16, Describe what is happening when you are having problems with your septic system, and when was this
first noticed? .
17. Do you notice the problem as being patterned or linked to a specific event (i.e., wash clothes, heavy
rains, and household guests ?) [ ] YES LV NO If Yes please list__AIA
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