OPHTE# t~-5-~63b3 Harnett County Department of Public Health
PERMIT Operation Permit 21 9 4 8
New Installation 'K Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
_ PROPERTY LOCATION: _E6 P,,_-_ ~t ,t L~1
Name: (owner) N t N o, 1r,_nQLG ~L62~cny NK_ SUBDIVISION % LOT #
System Installer: Ch-13 Registration #
Basement with plumbing: ❑ Garage ❑ Number of Bedrooms 3
Type of Water Supply: ❑ Community Well Distance from well t o0 feet
System Type: v1l o' 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.
mis system nas oeen mstauea in compuance wan appncame norm Lamina uenerai xatutes, nines for Sewage ireatment ana uisposai, ana an commons of one improvement rermit ana construction nutnorization.
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PERMIT CONDITIONS:
1. Performance: System shall perform in accordance with Rule .1961.
11. Monitoring: As required by Rule .1961.
111. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ No
If yes, see attached sheet for additional operation conditions, maintenance and reporting.
IV. Operation:
V. Other:
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewage disposal system on the above captioned property.
Type of system: El Conventional Other R-Z- Fl-o-~r Septic Tank: t ® O 0 gallons Pump Tank: gallons
Subsurface o. of exact length width of depth of
Drainage Field ditches of each ditch 4 feet ditches 3 feet ditches- inches
French Drain Reauired: ' eay,,,feet
Authorized State Agent , v 15 Date T15 1
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