OP'ITE# Harnett County Department of Public Health
PERMIT # a—j (z,—1 I Operation Permit
New Installation Septic Tank 'X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: N
Name: (owner)QT,S�.��� —��`� SUBDIVISION LOT #
System Installer: E+vy ) ,�— cKiA--+uL Registration #
Basement with plumbing: ❑ Garage Number of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well ! ®C? feet
System Type: 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
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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�l
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D -Box
Following are the specifications for
Type of system: ❑ Conventional
Subsurface No. of
Drainage Field 44�l
French Drain Reouired:
❑ Pump ❑ Alarm ❑ 1-12O1-ine ❑ PWR Line
the sewage disposal system on the above ca tione operty.
Other �Ntar� li � � Septic Tank: I0<50 gallons Pump Tank: gallons
exact length width of depth of
0 of each ditch feet ditches feet ditches )`� "�. inches
Authorized State Agent N�� � ���\ 2G--NAs Date G'2'4 11'
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