IPAC REPAIRHTE Harnett =737 Harnett County Department of Public Health 28369
Improvement Permit
A building permit cannot be issued with only an Improvement Permit
PROPERTY LOCATION:Ox /6-y2 00) /5L),Ws lZb
ISSUED TO:,'2/� rS �— SUBDIVISION LOT #
NEW I-] REPAIR EXPANSION ❑
Site Improvements required prior to Construction Authorization Issuance:
Type of Structure:
Proposed Wastewater System Type:U-
Projected Daily Flow: JG. ?� GPD
Number of bedrooms: Number of Occupants: max
Basement ❑Yes o
Pump Required: ❑Yes ❑ No Ma a required bed on final location and elevations of facilities
Type of Water Supply: El Community L/J Public LTJ Well Distance from well feet
Permit conditions:
Permit valid for.
Zr Five years
❑ No expiration
Authorized State Agents Date: `1 --3o - t � SEE ATTACHED SITE SKETCH
The issuance of this permit byte Ith 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, .1956. 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: /5�K (1-10 c_
Facility Type:' t New
Basement? ❑ Yes Q No Basement Fixtures? ❑ Yes
PROPERTY LOCATION: o > zJ /3u,Z--465 i2 -Q
SUBDIVISION LOT #
P, -Expansion Q Repair
21' No
Type of Wastewater System** Z1%, 4 s t -n
(See note below, if applicable ❑)
Installation Requirements/Conditions Number of trenches
Septic Tank Size D gallons Exact length of each trench 1 Z zs feet
Pump Tank Size gallons Trenches shall be installed on contour at as
Maximum Trench Depth of: 2q—)l t6ches
(Trench bottoms shall be level to +/-1/4"
in all directions)
Pump Requirements: ft. TDH vs. GPM
Conditions:
(Initial) Wastewater Flow: 3bo GPD
Trench Spacing: Feet on Center
Soil Cover: inches
(Maximum soil cover shall not exceed
36" above the trench bottom)
inches below pipe
Aggregate Depth: Z inches above pipe
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.
�Z inches total
**If applicable: J understand the system type specified is different from the type specified on the application. l accept the specifications 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 ownership of the site. This
Construction Authorization is subject to compliance with the provisions of the Laws and Rules for Sewage Treatment and Disposal and to the conditions of this permit )tt AI IALlitV Jllt NUILtl
Authorized State Age n Date: F 3 < ��
Construction Authorization Expiration Date: L - 3 6 zZ�)
HTE# 36-'137 Permit # 283C-7
Harnett County Department of Public Health
Site Sketch
PROPERTY LOCATON:
ISSUED T0:��,% SUBDIVISION LOT #
Authorized State Agen • Date: —/-5 —
... � A-)
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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
307 W. CORNELIUS HARNETT BLVD.
LILLINGTON, NC 27546
910-893-7547 PHONE
910-893-9371 FAX
Application for Repair
EMAIL ADDRESS:
NAME PHONE NUMBER
PHYSICAL ADDRESS 3CC LTJ 7j,
MAILING ADDRESS (IF DIFFFERENT THAN PHYSICAL) 3 oW2' (�Olf
IF RENTING, LEASING, ETC., LIST PROPERTY OWNER NAME l-_
SUBDIVISION NAME LOT #/TRACT # S ATE RD/HWY SIZE OF LOT/TRACT
Type of Dwelling: [ J Modular [ ] Mobile Home Stick built [ j Other
Number of bedrooms,. [ ] Basement
Garage: Yes KNo [ ] Dishwasher: Yes KNo [ ] Garbage Disposal: Yes No
Water Supply: [ j Private Well [ ] Community System County
/'�
Directions from Lillington to your site:-
ng
In order for Environmental Health to help you with your repair, you will need to comply by completing the following:
1. A "surveyed and recorded map" and "deed to your property" 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 your site is ready for 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, I 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.
Signature ---, U Date
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 [ ] NO
Also, within the last 5 years have you completed an application for repair for this site? [ ] YES [ ] NO
Year home was built (or year of septic tank installation)
Installer of system
Septic Tank Pumper
Designer of System
1. Number of people who live in house? ,-7 - # 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 used? [ ] daily [ ] weekly [ ] monthly
4. When was the septic tank last pumped? How often do you have it pumped?
5. If you have a dishwasher, how often do you use it? [ ] daily [ ] every other day [ ] weekly
6. If you have a washing machine, how often do you use it? [„.daily [ ] every other day [ weekly [) monthly
7. Do you have a water softener or treatment system? [—VY—ES [ ] NO Where does it drain?
8. Do you use an "in tank" toilet bowl sanitizer? [ ] YES "NO
9. Are you or any member iXN'O
r household using long term prescription drugs, antibiotics or
chemotherapy?] [ ] YES If yes please list
10. Do you put household cleaning chemicals down the drain? [ ] YES [ . NO If so, what kind?
11. Have you put any chemicals (paints, thinners, etc.) down the drain? [ ] YES
12. Have you installed any water fixtures since your system has been installed? [ J YES [O 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 [-,T'NO
14. Has any work been done to your structure since the initial move into your home such as, a roof, gutter
drains, basement foundation drains, landscaping, etc? If yes, please list
15. Are there any underground utilities on your lot? Please check ,all that apply:
[ ] PowerPhone [ ] 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 [ ] NO If Yes, please list