OPHTE# I5'S-!SS1 6 Harnett County Department of Public Health 23764
PERMIT # .)00"% Operation Permit
XNew Installation Septic Tank�itrification Line El Repair El Expansion
PROPERTY LO[ATION: (ely] Eo,xa AVIRfsL QZ>
Name: (owner) 1`ll6 NT' --N lI&v-c-cac )e- SUBDIVISION V-ioaEst: LOT #
System Installer: 9,1x ti-/ 4401-LA+vD Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms 3
Type of Water Supply: ❑ Community X Public ❑ Well Distance from well feet
System Type: 'SS=h Types V and VI Systems expire in S 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 Al conditions of the Improvement Permit and Construction Authorization
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PERMIT CONDITIONS
I. Performance: System shall perform in accordance with Rule .1961.
If. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ N
If yes, see attached sheet for additional operation ct
IV. Operation:
V. Other.
❑ D -Box
Following are the specifications for
Type of system: ❑ Conventional
Subsurface No. of
Drainage Fie
French Drain Reaujeed. 11
maintenance and reporting.
❑ Pump ❑ Alarm ❑ H2OLine ❑ PWR Line
the sewage disposal j! '� the LbGo1vptioned property.
Other
Septic Tank: J(LOC� gallons Pump Tank: gallons
exact length width of depth of
3 of each ditch S OO feet ditches 3 feet ditches lg inches
.L near feet
Authorized State Agent Date
► 5- 5-3ssl 6