OP RHTE# 0~' ypo- ~oN ~ Harnett County Department of Public Health 21 3 8 7
PERMIT # Q,- Operation Permit
Installationo~Septic Tank ❑ Repair E~jtrification Line ❑ Expansion
PROPERTY LOCATION: C
Name: (owner) SUBDIVISION V'j 0. LOT # -(,-_Z
System Installer Registration #
Basement with plumbing: ❑ Garag mber of Bedrooms
Type of Water Supply: ❑ Commum Public ❑ Well Distance from well 02 feet
System Type: IV- 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.
IIIU srslem nos peen Instanea in
with applicable North Carolina General Statutes, Rules for Sewage Treatment and
and all conditions of the
Permit and Construction Authorization.
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1. 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 ❑
IV. Operation:
V. Other:
If yes, see attached sheet for additional opera conditions, maintenance and reporting.
Following are the specifications for the t e disposal systcral on the above captioned property.
Type of system: El Conventional Other A c V` ~ C~fy~~~~ Septic Tank: gallons Pump Tank: gallons
Subsurface No. of - e act length , width of depth of
Drainage Field ditches of each ditch feet ditches 12> feet ditches inches
french Drain Required: Linear feet
Authorized State Agent ~J Date J
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