OP - Repair/Expansion due to storage bldg - no IPACHTE# DI 'S — 1333k Harnett County Department of Public Health 24340
PERMIT # 0 enation Per It
❑ New Installation Septic Tank ❑ Nitrification Line ❑ Repair O/Expansior
PROPERTY LOCATION:?:KJci2 Ak,ac4� /C/Q
Name: (owner) Agl� /Z-4/e/ag;fAWIVISION LOT #
System Installer: a Com! a Registration #
Basement with plumbing: ❑ Garage Number If Bedrooms Z
Type of Water Supply: ❑ Community 9 Public ❑ Well Distance from well feet
System Type: /_ 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 all conditions of the Improvement Permit and Construction Authorization
PERMIT CONDITIONS
I. Performance:
If. Monitoring:
III. Maintenance:
IV. Operation:
V. Other:
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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 ❑ Alarm ❑ 1 -1201 -me ❑ PWR Line
Following are the sp!e�cifications for the sewage disposal system on the above captioned property.
Type of system: E Conventional ❑ Other Septic Tank b00 gallons Pump Tank: gallons
Subsurface No. of _— exact len _ width of _ depth of
Drainage Field ditches of each ditch feet ditches feet ditches inches
French Drain Required: Linear feet
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Authorized State Agent<::)5x -, / "' ' / J� J c Date � — q - /7
L/
01-5-1333R (2)
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01-5-1333R (7)
01-5-1333R (3)
01-5-1333R (4)
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01-5-1333R (5) 01-5-1333R (6)
01-5-1333R (8)
01-5-1333R (9)
01-5-1333R (1)
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
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MAILING ADDR ESS (tF DIFFFERENT THAN PHYSICAL)
IF RENTING, LEASING, ETC., UST PROPERTY OWNER
SUBDIVISION NAME T
Type of Dwelling: [ ) Modular
Number of bedrooms
Garage: Yes J No t1 -
Water Supply: [ [ Private Well
LOT W/TRACT 8
( [ Mobile Home
( ) Basement
Directions from Ullington to your site:
-7 ,, Jr A� I C ;-f
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EMAIL ADDRESS: IU�4o.�l3=6Q
'HONE NUMBER_ l ii - -(P15 --J (o t{9
STATE RD/HWY
Wt -ick built [ ) Other
Dishwasher: Yes [ ) No [iY
1lcommunity System ounty
0
SIZE OF LOT/TRACr
Garbage Disposal: Yes [ j No ft-�
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 man" and "deed to vour 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 ownershl. rti�
Signature
Date \` 1
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? [ j YES [c}Nm
Also, within the last 5 years have you completed an application for repair for this site? f j 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? _ ( # adults p children -# total
2. What is your average estimated daily water usage? ,2L Q gallons/month or day Gv 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? [ j daily [ ] weekly [ j 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 [ j every other day [ ] week)
6. If you have a washing machine, how often do you use it? f I dally f 1 every other da Y
7. Do you have a water softener or treatments stem? i [Iain? f J monthly
y (]YES [ ] NO Where does k drain?
B. Do you use an "in tank" toilet bowl sanitizer? ( j YES [ j NO
9. Are you or any member in your household using longterm prescription drugs, antibiotics or
chemotherapy?] [ ] YES [ ] NO If yes please list
10. Do you put household cleaning chemicals down the drain? [ j YES [ ] NO If so, what kind?
11. Have you put any chemicals (paints, thinners, etc.) down the drain? [ j YES [ j NO
12. Have you installed any water fixtures since your system has been installed? (] YES [ j NO 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 [ j 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:
[ ] Power (j Phone [ ] Cable [ ] Gas [ j 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?) [ j YES [ j NO If Yes, please list_
HTE# - 5 -IV- `R �-3
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME OAIkt0►9�n �IYIu/k�f PHONE# 9rq-G�s zLys
ADDRESS A6- 941
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT) 5fK ze #a,, -,n-_ - �
ADDRESS OF OWNER (IFDIFFERENT) /�/y5 ryi✓�i { n �? A�(�.��5?�
PROPERTY LOCATION: STATE ROAD NAME AND #
PURPOSE OF INSPECTION: �%� 1 1 'K. 7� „�!t `
The aforementioned site has been evaluates Irnett C health Department .
Environmental Health Section. At the time of inspection, there appeared to be a septic
system serving this site. If this system should malfunction, the owner is responsible for
any necgssar ► repalr�,
..aS�u.I+:Y Vinr$.5,✓.. .�'a'.a,s,
THIS INSPECTION IS VOID IF:
(1) the intended use of the septic system should change, and/or
(2) the system should fail or malfunction, and/or
(3) the owner or tenant of the property changes, and/or
(4) after six months
BUILDING MUST BE 5' FROM ANY PART OF SEPTIC SYSTEM �a
400 NOT DRIVE OR PARK ON SEPTIC SYSTEM
e AUTHORIZATION OF EXISTING SYSTEM
d
SigtWture ofnE vironmen al Health Specialist Date
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