OPHTE# II-57- 0°72 96 Harneh County Department of Public Health
PERMIT # Operation Per it 22073
Q/ New -
Installation 2 Septic Tank L1 Nitrification Line ❑ Repair ❑ Expansion
PROPERTY LOCATION JJ0 7 40%6 Zb
Name: (owner) ~ SUBDIVISION LOT #
System Installer: Registration #
Basement with plumbing: ❑ G /rage umber of Bedrooms
Type of Water Supply: ❑ Community Public ❑ Well Distance from well feet
System Type: , 21&(LA p , % 0041 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.
This system has been installed in compliance with
North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization.
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PERMIT CONDITIONS: f`
1. Performance: System shall perform in accordance with Rule .1961.
II. Monitoring: As required by Rule .1961.
III. Maintenance: As required by Rule .1961. Other:
Subsurface system operator required? Yes ❑ No ❑
If yes, see attached sheet for additional operation condiA
IV. Operation:
L,yy9i) 41
maintenance and reporting.
V. Other:
❑ D-Box ❑ Pump ❑ Alarm ❑ H20Line ❑ PWR Line
Following are the specifications for the sewer disposal system on the above captioned pro er .
Type of system: ❑ Conventional Other 16% Z" :U jT 6 Septic Tank: P&O gallons Pump Tank: gallons
Subsurface No. of exact length width of depth of
Drainage Field ditches of each ditch 60 feet ditches '3~ feet ditches -71 inches
French Drain Required: Linear feet
Authorized State Ag nt Date /
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