OPHTE# t 1--5-'~ Harnett County Department of Public Health
PERMIT # amt i~l Operation Permit 21 9 5 0
New Installation Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION:
Name: (owner) \~o n SUBDIVISION ~.cz o L> a O s>,,c s LOT # 5 yi
System Installer: c -7~ ®'A ~S Registration #
Basement with plumbing: ❑ Garage '14 Number of Bedrooms 3
Type of Water Supply: ❑ Community A Public ❑ Well Distance from well 102 feet
System Type: ~r 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 peen mstauea in compuance wan appncame norm Lamina venerai statutes, KUM for sewage ireatment ana uisposai, ana an conanions os me improvement rermit ana Lonstrucnon AUtnorization.
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PLKMII LUNDIIZUNI:
1. Performance: System shall perform in accordance with Rule .1961.
ll. 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 ❑
following are the specifications for the sewage disposal system on the above caption property.
Type of system: ❑ Conventional Other (Q Lh Septic Tank:
Subsurface No. of exact length width of
Drainage Field i`ditchesy of each ditch 165 feet ditches
French Drain Reauii, Usear feet
H20Line ❑ PWR Line
gallons Pump Tank: gallons
depth of
feet ditches inches
Authorized State Agent 4---'j Date S1(:
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