A28 134PERSON COUNTY ENVIRONMENTAL HEALTH
'ACHED PLAN FOR SOIL AREA AND SYSTEM t
Tax Map #: l��� Pareel � � iJ 1
Zonin9 Township 1� Q- � �.
ApplicanC /�} �/ � � � C OL
�ocaUon: ��_T��. 97 lU: �0 LI.- �(\ :('v � d T fl _ 1 Y� ;N I/1.n� KLC _
Subd(vislon•�10 W�°� W�t(li-f VSID secUon: �oc: _�_
Improvement Permit
A buildinq permit cannot be issued with only an improvement Permit
New V Repair Addition Type of Strudur��� Wate� Supply r� � W� `�
�
# of Occupants . Q� #�of Bedrooms � Other
Basement? Basement Fuctures? j�Q_
Projected Daily Flow: � g.p.d. Pertnit Valid For. �'F'rve Years ❑ No piratio
Proposed Wastewater ystem Type: l71,( m,rl !� � n+f�b �.l ��)
Pump Required? Yes No
Proposed Repair :'� „„-� ip P a�A ,�
Permit Conditions:
Owner or Legal
Authorized State
Date:
Date: �
The issuance of this permit d�t�e Heafth Departme�t in no way guarantees the issuance of other permits. The permit
holder is responsible for chedcing with appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use changes. The Imp�ovement Pertnit shall not be
affected by a change in ownership of the site. This pertnit is subject to compliance with the provisions of the
Laws and Rutes for Sewage Treatment and Disposal S stems of the North C I' Ad '' trati C d
y aro ina m�nis ve o e.
Authorization To Construct Wastewater Svstem (Required for Buildinq Permit)
Type of Wastewater System � Wastewate� Flow: .�Q.p.d.
Facility Type: � New �ir DExpansion 0
Basement? 0 Yes g,Pds Basement Fixtures? 0 Yes q,DJ6
Wastewater Svstem Requirements �
Septic Tank Size: �_ gallons Pump Tank Size: �� gallons
Total Trench Length:l"_ � 6a feet Maximum T�ench Depth: 2.�-i inches Aggregate Depth: � zin.
Maximum Soil Cover. � Z inches Trench Separation: � Feet on Center
Other.
Permit Expiration Date: �D' � -�
Authorized State
The type of system pertnitted ❑ does 0 does not ' e, om th type specified on the application. I accept
the specifications of this permit ,'
�
OwnedLegal Re resentative Si natu� :��� `���� .���—G�
P 9 � � � Date.
PCHD, rev.11/18/99
Application #:
Tax Map #:
Parcel #• T'-�
• Person County Health Department
Environmenta! Health Section
.
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SubdivisioN ectioNl.ot#
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Date
System components represeni approximate contours only. The contracior must flag the system
arior to beginnin� the installation to insure that proper �rade is maintained
�°13'
Scale: � � � : ��'
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PCHD, rev.10/12J99
. Person County Heaith Department
' Environmental Health Section �
Tax Map #: ��� Parcel #: �
Zoning: Township:
�I� u� � II
Subdivision: bwh ��u k I r Section: o� l
' (.J r�l�1S�t-e0.�
Applican� � � `�
f (�, � j
Locatiom � S R oGl�. 1 �� L +� � r I a ��
�
Operation Perm it
�
System Type (In Accordance With Tabie Va): 1 �� �
THIS SYSTEM HAS BEEN INSTALLED IN COMPUANCE WITH APPUCABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEINAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHO IZATi
� !� o-o
� Authorized St Agerrt Date
PCHD, rev. 10/12/99
Person County Health Department
Environmental Health Section � � I�
Zoning: Townshtp: � I � Ve- �� ' � �
Subdiviston:� 1� 0�'�� l,() �� 5ectlon: Lot: �
Applicant: �� �S
Location• �iS �IOG� �� , r w�►�l
. � Q�I � • �� �
Operation Permit �
1. LOCATION AND SEPARATION DISTANCES �
A) System meets .1950 setback requirements �_
B) Distance from system to any welis ,i�loo �
C) Distance nom septic tank to foundation {,��
D) Distance from system to property lines lO� �,n�ri�►ctn�►
2. SEPTIC TANK eS
A) Visually inspect the exterior walls and top of the tank �
B) Visually inspect the interior walis, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet CS
C) Date of tank manufacture a u►�►��o'�,►,�Y $�4�l00
D) Tank serial number: � �
E) Liquid capacity of fank � gallons
3. SUPPLY LINE TO TRENCHES
A) Grade �� dra�' (1/8 inch per foot minimum)
B) Material supply li e is constructed from se.a 4a �y�
C) Diameter 3 `'
D) Length 3�' � �
E) Distance from tank to drainfield/distribution device 300
4. DISTRIBUTION DEVIC (S)
A) Type N�
. B) !s Device water tight �_
C) Distance from the disfibution device(s) to the trenches �'�
D) is the device on a level foundation ,�_
E) Does the device perform according to its design specifications 1JL�..,
F) Record the iniet and outlet elevations N�-
5. NITRIFICATION FIELD
A) Trench depth �,�inches
B) Trench width 3 G inches r -�-
C) Distance befinreen Venches q On �'G'�'//�°i'
D) Number of trencties ^ /� 1
E) Length(s) of trenches // t�, / l7 . 113, lv0 (� �� ��°�
F) Aggregate depth �_ inches
G) Aggregate material and size � 5 7
H) Record septic tank o�}tlet etevation � See vc�cd:�
I) Trench grade �e Cl G✓l (< 1l4" per 10')
J) Step downs
� a. Minimum of 2' of undisturbed earth �
b. Proper rise over step down �
c. Solid pipe used J�S '
d. Elevations of step ownsS �`'`�`(�cord elevations and show on as built)
See "as buiit" plan on attached sheet.
PCHD, rev. 1Q/12/99
� i
' • PERSON COUNTY ENVIRONMENTAL HEALTI
Date: '
Owner: ��
Location/Directions:
Subdivision Name:
Drilling Contractor:
WELL LOG �
>
� lV,y � � � .S-� eo. SR#
Lot #
WELL CONSTRUCTION �
Distance from Nearest Property Line 1 c1 Distance from Source of
Pollution ( G a
Total.Dep.th: l O Ft. Yield: " GPM Static Water Level a.S—' Ft.
Water Bearing Zones: Depth (�___Ft. Ft F� Ft.
Casing: Depth: From 6 to � _Ft. Diameter:_!�_Inches
TYPE: Steel � Galvanized Steel .�
If Steel, does owner approve: Y�s No �
Weight: Thickness:� � Height�Above Ground: /�% Inches
Drive Shoe: Yes ✓ No .
Were.Problems Encountered in Setting the Casing? Yes No �
If "yes" give reason: �
Grou�: Type: � Neat Sand/Cement / Concre[e
� Annular. Space Width Inches
Water in Annular Space: Yes No
_ .. Method: Pumped - Pr:ssure � � Poured � � - � � = �
Depth: From O to �, O Ft.
Materials Used: No. Bags Portland Cement Weight of .1 ba�_lbs.
If mixture (sand, gravel; cuttings) - Ratio: to
ID Plates: Yes � No � �
� 4 x 4 slab Yes � No
I HEREBY CERTIFY THAT THE ABOVE INFORM�TION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY�THE PERSON COui�iTY' HEALTH DEPARTMENT.
� ,
_ ` __ �����0
S ature of Concractor Da��
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR WELL SiTE LAYOUT
Tax Map #t � o� C� Parcel # `��
ZaNng Township � � r `� � �`� 11
� 1- - � ,,, 1�,.. ► .� � �„`.� l,Ji U � e��\
APPlicanC _ � _ . „ .
�
Locatlon: � � �
£ 1_ �_
SubdNlsion• 'H- Sectlom �
Tvpe of Water Supplv:
Requirements•
Site Approved by _
Grouting_Approved
Well Log t/�S
Well Tag a/ , S
Air Vent �s
Hose Bib—�
Concrete Slab �g
�
2
�
Well Permit
ndividuai
/
s�
. Communiiy � Public
Welt Driller• ��'�.�
WeII�Approved By: Date• �� � � �
**See Attached Site Sketch*'"`
Wells must be 10 �et ftom property lines.
Weils must be 100 feet from septic systems.
Welis must be at least 25 feet from any buiiding foundation.
Other conditions:
PCHD, rev. 11/29/99
'I'ype �I (b) Systena �nspection Checklist
Tax Map �� Parcel #: C� PIN
Owner: Subdivision: �
Address: Ph/Se /Lo :
Location: � �
1�). _Establishment_._.. ._. _._._ . _ . _.
a) type, size and sewage flow in
accordance with pernut
2) Tanks
a} tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good worldng condition
d) tanks pumped, cleaned out as needed
3) Effluent Dosing Svstem
a) effluent appeazs clear, free of excess solids
b) required pumps present, operating properly
c) high water alarm present, operating
properly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) control panel enclosure and components
in good condition, operating roperly
fl Drawd'own rate: � S—
4) Ground Asorntion Field(sl
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, tile drains are
well maintained �
d) soil cover, vegetation adequate and
maintained as needed
e) protected from traffic and destructive uses
fl distribution devices in good condition,
worldng properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted ..._
YES NO Remazks
Summary of Improvements and/or Itepairs Needed:
�
�