OPHTE# Sd"5; °i Harnett County Department of Public Health
PERMIT # 914-,,`'I D Operation Permit 2 21 3 4
New Installation 'K Septic Tank X Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION: vnsszy 19Q
Name: (owner) QN41 rvC:5S SUBDIVISION LOT #
System Installer: PCac.~GL C~as»N~ Registration #
Basement with plumbing: ❑ Garage 'X Number of Bedrooms Lf
Type of Water Supply: ❑ Community X Public ❑ Well Distance from well ! e6 U feet
System Type: T 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.
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 ❑ Nox
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 roperty.
Type of system: ❑ Conventional , Other E7Z N7i Ed "~4 U? E.' , ~1-:' Septic Tank: NU®~ gallons Pump Tank: 101Z) ® gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch feet ditches feet ditches inches
French Drain Required; ~zz,
Authorized State Atrent _ Date
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