OPHTE# �s =S=3-rrro8 Harnett County Department of Public Health 23915
PERMIT # 7— Operation Permit
L?" New Installation Septic Tank Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:*EariWo T - Ab
Name: (owner) /7&y- 04� ^Ae /_.o—neQNec. SUBDIVISION LOT #
System Installer: �e�lar Registration #
Basement with plumbing__: Garage %N ember of Bedrooms 3
Type of Water Supply: ❑ Communitylfi" Public El Well Distance from well feet
System Type: �yI -n '0 ;5 .54Cr 4 �'e. 22.5� 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 Noah Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Gonstromon Authonaanon.
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PERMIT CONDITIONS:
1. Performance:
II. Monitoring:
III. Maintenance:
IV. Operation:
V. Other.
System shall perform in accordance with Rule .1961.
As required by Rule .1961.
As required by Rule .1961. Other.
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
❑ D -Box ❑ Pump Cl
Following are the spec cations for the sewage disposal system on the above captioned property.
Type of system: Conventional ❑ Other
Subsurface No. of exact length
Drainage Field ditches Z of each ditch /Y6 feet
Alarm ❑
H2OLfne ❑
Septic Tank: /006 gallons Pump Tank
width of depth of
ditches 3 feet ditches / 8
French Drain Required: Linear feet L
Authorized State At n�t � �i�.�ir�i
C �Y � Date
PWR Line
gallons
inches
15-5-37768 (1)
15-5-37768 (2)
15-5-37768 (3)
15-5-37768 (4)
15-5-37768 (5)
15-5-37768 (6)
15-5-37768 (11)
15-5-37768 (7)
15-5-37768 (8)
15-5-37768 (9)
15-5-37768 (10)
Notice to Homeowner Declaring Exemption from Article 5 Chapter 90A
HAM, --^7T Environmental Health Department has received
County
notification A�uvie �Y7,44dnCr shall be declaring the exemption
Homeowner
as Homeowner under N.C. General Statute 90A -72(b)(2) to install and/or repair an on-site wastewater
system. In order to protect the environment, the Environmental Health Department advises if Homeowner
does not have prior experience in on-site installation and/or repair that a person certified by the North
Carolina On -Site Wastewater Contractors Inspectors Certification Board (NCOWCICB) be hired to do
this service. Please be advised that Environmental Health Department reserves the right to be present for
any and/or all parts of the installation and/or repair process including excavation and cover-up.
In order to declare the exemption all of the following requirements must be met:
L3Aystem must be a single septic tank
�ystem must be gravity fed
,system must have gravel trench dispersal media
erson listed as Homeowner must own property
Property must be intended solely for use by Homeowner
and members of homeowner's immediate family who reside
dn the same dwelling
1
Homeowner shall perform installation and/or repair labor
without any monetary exchange or other means of payment for labor to any party other than a
person certified by NCOWCICB
By signing below, the Homeowner hereby acknowledges the above statement.
Date L.i �_n_,)Z:4
Homeowner Signature
0,4 one d'oed4F7^
Printed ame
STATE OF 41 ,f� C4"2r;04 DAWN HICKMAN
Notary Public. North Carolina
hnston
COUNTYOF t&R+JaT JoMy Commissmiss County
ion Expires
ISI October 10, 2018
`f 4�0, n the undersigned Notary Public, do hereby certify that
personally appeared before me this day and
acknowl ged the due execution of the foregoing instrument.�nQ �—
yo
WITNESS m hand and notarial seal, this the ��) day of'' or �I '� A� �� 0
n,. `8�
(SEAL)to , Notary Public
My Commission Expires:
CC: File
LEHD
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