OPHTE# ! 3 - -- 31131 Harnett County Department of Public Health 23177
PERMIT # Z-7 4 {a
ZNew Operation Peermit
Installation ® Septic Tank D"'Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: i s °xr .' Q1, v z - f 24 °1
Name: (owner) v" .55 SUBDIVISION LOT #
System Installer: , '*S / a `,fL1(cr , >� Registration #
Basement with plumbing: ❑ Garage 12-lumber of Bedrooms 7
Type of Water Supply: ❑ Community ❑' Public ❑ Well Distance from well feet
System Type: '2-5/ o 1Z2,00 C..4 a `> s f 'L, :.0 C e (-- pes V and VI Systems expire in 5 years.
(In accordance with Table uwner MUSL con ac a ith DepffN—enTriff0n6s—pFtoTn expiration for permit renewal.
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
and al conditi Ps I the Improvement Permit and Construction Authorization. f�
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PERMIT CONDITIONS:
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:
V. Other:
❑ D -Box ❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
following are the specifications for the sewage disposal system on the above captioned property.
Type of system: ❑ Conventional E!f Other Zil-rZ "rt3 UL -- -S-t,1 Septic Tank: gallons Pump Tank: gallons
Subsurface No. of 7 exact length '40 width of depth of
Drainage Field ditches of each ditch feet ditches => feet ditches l inches
French Drain Required: Linear feet
Authorized State Aunt .,. % _ Date Ll " ,3 0 ` I }
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13 -5 -31439 (26) 13 -5 -31439 (25) 13 -5 -31439 (24) 13 -5 -31439 (23) 13 -5 -31439 (22)
13 -5 -31439 (21) 13 -5 -31439 (20)
Temporary Ezflow /Chamber certification
Richard Moss
Yellow dog grading
Po box 577
Lillington nc 27546
F910- 893 -6362
C 910 -890 -0382
Mr. Moss
Please let this letter serve as temporary for ezflow and chambers. You will receive a certification in the
mail from our corporate office.
Thanks
William Woodward
ISI
Sales
Important Note: General Contractor Waiver /Exemption Form has been reviewed by NCOWCICB and
deemed acceptable. However, this form is not a requirement by NCOWCICB and is being published as
a service for those parties that choose to use this form.
NCOWCICB General Contractor Waiver/Exemption Form
I �` FC�x ` �� , am a North Carolina General Contractor licensed under Article 1
of Chapter 87 of the General Statutes. My NC General Contractor's # is (a copy of the
current license MUST be attached to this form or it will not be accepted). I certify that myself and/or my
employees (employees must be on the payroll and must have W -2's filled and taxes taken out on them or
they can not be considered employees) constructed, and/or installed the wastewater system for the
property located at: - .� 1 b 7-\��,e, e� Afz k`-- . According to NC General Statues, Article
5, Chapter 90A -72 ( b ) ( 3 ) A person licensed under Article I of Chapter 87 of the General Statues who
construct or, installs an on -site wastewater system ancillary to the building being constructed does not
have to be certified as an On -site Wastewater Contractor. This does not supercede the requirement for
certification from proprietary system manufacturer. By signing this document I understand that I am
taking sole responsibility for the construction, and/or installation of the above mentioned wastewater
system. I also understand that this document will be attached to the final signed off septic permit and the
Operation Permit, when issued.
Signature and Date:
Printed Name and Date: 1� `' �`� � `zy Zo IY
STATE OF P t""
COUNTY OF 14-0
1 4-Z116 ` 1s5 , the undersigned Notary Public, do hereby
certify that , personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
WITNESS my hand and notarial seal, this the day of 20
My Commission Expires:
43
Notary Public