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A29 104r,`. . � �'h � District Health Department GASWELL - CHATHAM - LEE - PERSON COUNTIES Wa$er Supply ond Sewage Disposal IMPROVEMENTS PERA�IZ-i�Tj�_ �,Ij te 4 Owner = �u �� '� �- `�� Location: _, , t , _. �=----- _,��_ 1 `� - l t� �_: , Contractor: v � t � Water Supplp: Private � public � Sewage Disposal Facililies: No. bedrooms � Dishwasher, Disposal, washing machine, other automatic appliances _ � , � ��'� ��., i Size of tank: �, __. Nitri('ication 1 i' J '/ . (�ther disposal facility: �I �ater supply and se�'age clisposal facilities location, installation ar protection must meet state and local regulations. Septic tank should be pumped out every 3 to 5 years an3 shall be main- tained by owner in such a manner as not to create a public health hazard. Septic tank and nitrification line MUST BE INSPECTED AND AP- PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT ERED AND PUT N USETION OF THE INSTiALLATION IS COV- �, ,, � i i % /� � i'� p �- % �-`�1�~� ; �1 �" ,�:i.�;; Date approved: Signed - � /.:�'):i;%�'� �' Sanitarian' Well: , � Sewage Disposal: By: Counter=�f,;--., 'r` + y � signed �,. , ��c,; ,' 'r. � . (Owner or his represen4ative) --- �. _. �Certificate of ComPletioa � - " Date Approved: � ' By:� (OYER) Location of well and sewage disposal facilities sketched on back. � 0 NOTE: sketch of install ti n showing lot size anIII ape, location of house, septic tanks, pr� water u lies e ote s ecial roblem existin on lot. Write 111 �asurements in order h 1' s pp , p p g t at instal ations may be located at later�te. Note location of water supplies on adjacent lots. � � i; � f �, ,11 � . ,,, ...�.��...�,.��w� ...� _—._�..... �2, �� . . , a.� Y,�..,...n.r��.-�� , ,,� -Y-� � ----u��.. � ..� ."+.-� ' � f" i , � i i � � � 4 • -, , � - � , l � a � -_ _._ ... . _ -- _.> - ��.: •��;�1 - � �`�`� � � �� 2 Application Date: � �� +SS �� Amount Paid: ��.(7(j�.0<� Receipt #: 2�+� 0 � � � � �� I -Cy.�rav-na-rc�,.*,.x,� �:and.s..11 JL�I�.a.lLdlia. ' �' � g�*�a j 3� Aanlicatl'zon for Services 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) D Mobile Home Rsglacement or Building Arldition $150.00 (if site visit required) 0 Well Permit (IVew/Replacement/Repair) $300.00/$200.00/$75.00 Tax Map: Parcel#: � r , ,�' _ .� � � �� Services Re uested � Construction Authorization (Fee is de endent on the ty e of system ermitted) J Permi: Revisicn $75.00 0 Repair of Existing Septic System Application: No Charge/ CA $ I50.00 or $300.00 �� L 1) Applicant Information: Name: Phone (home): 3.3 G- S a�j — 2�%3%� Address: Z, e G (work/cell): 336 - 5 9 9-/ S�zS � RoX�nYr� �t/r^�2�s'�� `rOM-336-��3-�-i�7c�'' 2) Name and address of current owner (if different than applicant): Name: Address: Phone: 3) Property Descrjption: Lot Size: Subdivision: Lot .#: Address and/or directions to Property: � GboV e o. Y�cs S- ❑ yes �( no Does the site contain any jurisdictional wetlands? 6�yes ❑ no Does the site contain any existing wastewater systems? ❑ yes � no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes A no Is the site subject to approval by any other public agency? ❑ yes .� no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: �Residential �� ❑ New Single Family Residence Maximum number of bedrooms: . j� Expansion of Existing System If expansion: Current number of bedrooms: �� /1�� jys �e� ❑ Repair to Ma?functioning System Will tl:e:e b� a b�sement? ❑ yes � no Wi:h plumb:ng fixtu::,s? � yes �:.o ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well � Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wel(s, springs, or existing waterlines on this property? � yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional �3f Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any 1 cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or ifthe site is,sub�equently altered, or the intended use changes, all permits and apnrovals shall be invalid. Signature (Owrier/ Legal Representative*) '� Supporting documentation required. �� I �-� 01.� Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) + �� , ��.� �L.1/ �\� .�, .. ,,� `�'� . . -�...�� 7I�.�'�.�cCDa^� �r'n"'� ��.Sff.� ��.�'�.11'n. ` • � . � � / � . � � � � i� � � _ �.�i��3:.� T�x Map � � �i•c�el : �S��i,bcl;i�i s�i�o n � 1h �,s�P' �S�+i,o�ILolt � Inaprovement �ermit ' � ��rmi# �alid �or � �ve 'i�e�s rTo �apiration Type of Facility: 3�ia�� S New Addition� �ate� Suppiy �` �e� i. # of Occupants�k4Y � of Bedrooms __u� Projected Daily Flow 3 g.p.d. b Proposed Wastewater System: Cevt ' � Type: Proposed ReQair: Q' C i-e . � TYPe' Permit�Conditions: SP�2 St�-�2 �ila+. Owner or Legal Representati Da#e: Authorized State�Agent: D�� The issuance of this peffiit by the Health Depar�nent in does not guarantee the issuance af other peimits. It is the respons�bili .ty of the � applicant/pzoperiy owner to in sure that all Person County Pla�ming and Zaning and Building Iaspections requirements are met This Improvement P�rmit i� snb ject to revtication if the siie plan, plat or the intended use changes. The Improvement Permit is not a�ected by a change in ownership of the properiy. , This permit was issued in compliance wit6 the prnvisions of the North Carolina �Zaws and Rules {ar Sewage Trea�nent a�d I)isnosal Svstems'- (15A NCAC 18A .1900). Neither Person �ounty nor the Environmental Health Specialist�warrants tlaat.the septic tank system w�71 continue tn function satisfactorily in the future or'that the water supply will remain�potable. - - . . - � - - �. Authorization eo Constract Wastewater Sysfem (Reqni;ed for Btu'lding Permit) * See site plan and adrlitional attaehments� (_�• . - Proposed Wastewater System: ��/1�1 ��a � � Type �6 Wastewater Flow �-g:p.d. New �, Repau Exp nsio _ � Soii LTAR.: 3� g.p.d1 ft 2 � Type of Facility: � , � '�� P S Basement _ Yes No � � , '�ank Size: Septic'�ank: �D90 gai �asteevater Systeffi Rea��ir.e�aen�s � Pnmp'Tanic: �O�Ogal �GreaseTrap: — gal �rain�eld: 'Total Aa�ea: iZoO sq f� -Total ]Length �f D� ft Tremci� dVidtD� � ft Nginiaauna Soi� Cmver: �^ in �istagb�ataon: �ii�tribn�om �oa Speci�cations: AIIT.�lOICIZEi� �tdtE. A��E�i T�� Permit Exp' � on Date: �ial �istriibntion �� 1Nda�mnm Trench Depth � � in 1dIinim� Trencli Separation: �_ ft � Pressnre Manifold L$L�: The type of system permitted is �' C�nventional Acce�ted Alternative. I accept the specifications of the i�w��r/��gal �8�pses��tativeY� Date: �� i� Z-��.Z ' pG� rev. 11/10/OS ��---..�� . 1 �� n�v�-n�c-�a�n.�r,r�. ¢��an� �'��.Il.��n Sloped To Shed Water i5" Cover • ..� Inlet Fmm Septic Tank 4" SCH 40 PVC Pi.pe NEMA 4X Simplex Contzul Panel x I-7 +F" X 4" Pressure Treated Post j 12" Separation Electrical Coxu3uit -- l . , � • � Access Cover• •• , ' . ; � 1 ; . _ �. � � ' � . ; • ��• • ' . ; �.. Opening Filled With Anti Siphon Hole \ Portlan,d Cement Gzaut �� g�� C�Zck Valve High Watex Alaxm Level " (6" Separation� , High Level- Pump On ---�.�� / �Vapor Lock ' �. �� C% Hole _ ,. . � __[__Drawdrnm �Up Hi71) � � , Law Lev�el -Pump Ofi -�-1' ' r'' . , , Precast Coz�crete Taa]c � � ;.; (Material Strengtk �3500 P � . . r . . i �.`. . . . •. � . T�x M�� ' P�rcel # " Su�hclivisioii Ph��se SQct�ion` ot # � Duct SealBoth Ends Of The Con,�.iit �- 24" Minirre�m ,. ., . -• , • .. , . Threaded G fte Yalve • Zip Cv Ties Rnpe 4" Conaxete s��k . + .r � • . • . • � �� • Concnete Riser b" Separation - . •, • , :r..c�y�' • 'k�.�-Portlazid Concrete Gxout Mastu • - ' . � Opening Filled With Supply ' : portlandCementGzaut Lixie • • ' Outlet To Distnbutiox 2" SCH40PVC Pipe Float Wires �' � �r i• Fl�oats .: �R.exnovable '.:' .' F1oat Trne , r � � j. •, \ ��-1, •.• .. � ��Lar� � z�x ��,�� ]PI��.�� --= �-�= �� .�/ I lE�.-��mm � ��¢�.11 IHI�.�.Il,E� Owner: �u( �NK S'�► Tax Map: 2� Parcel #: �� Date: S& l z I.ine B'ap 'Tap (Sch) Tap �'low� Y.ine I,eaagth �'1oe�v / foot # Diameter(in) ( m) �;� (ft) � 2 �ro 5. o ► d 9 B 1 2 � O � �� 8' 3 3 �a 0. nc�� .lD � � z d . 8U � � D 8-� 5 l� D , ' �D� 6 7 8 9 10 � D O ft of line x 65 per 100 ft= 2�� '� ; 100 =z� a gal 75% x 2(�F� ga1= 1�� gal per dose �.� gal per minute (gpm) = k'low I�ate �riction �ead I Loss: 3� o ft per 100 ft of supply line x� g � ft of supply. line = 100 = S� 5 ft s. S ft x 1.2 =� ft of friction head �. Manifold Size: 3 "�'orce Main Size: 2" PVC Total Dyaamic �[ead =,��ft of Elevation head + Z ft of Pressure hea,d +�ft of Fricrion Head = Z� TDH Pump Requirement: � GPM @ Z3 • ft of Head Drawdown: / Q�gal per dose � 21 gal per inch = �_ inch drawdown per dose �� .r..,�.,� � � ��>,,�� , � � �� -- _��t0 — ��.,, ��,,: . . . . . . . , �• 1 _ _ ��t�1'� ,.. �[(�)1��0� 11 II 111 II .:::�..:::.°:::�:::..::::::.:::.: .. ..� . iilt!!!!!!l��Nl�l��l��:l�!!!!! � � � � r • : i ., _ c :1 � : : : Y: i.m.►� ]awl/ma� --� 9m� '`� s . $IZa /'r�'i:1p3 Tio. Taps uff one 3" » �—{D7 � 40+ � z3 � ss—J . . . . - . " Fiow sr'TaP Size IYlcnerial FTow G?3�I !�" Sc&ed80 �.� . 1, " Sched 10 ?_1 5, �• �ched 80 I � 1 ;, . �ched ?0 I-.� :1 � . �� s I�I�I�.� �I� . - � -� �� IEaa�aa-m�,.,"•,• maa.�mm.Il � IHI��.Il�]!a SI'TE PLAN Name _� VO K�oyl ' Taa Map #,� Parcet #�� Sub ' ' � Secrion/Lot# Z Authorized State Agent Da e '� System compaaeais rrpnseat appmazmare eontours oa1y, The contracmrmust 9ag tGe sysum priat m begiaaiag the iastallatioa m tnsurr �atpmpergrrde r's mamtaiaed _�,.� � � �� o �0a�� t o �p o�''� �• � � �- �� i � �� `� �� .' � � ^� .s . .�� -. � �- � � �? fi � � � � � � , � , .-� � � � � fb � ,� _ x S � � d � . z„ Sc �, �a f'�"�i° l �,e ,' � `� � : �� o � � �h � � ��. ss ��.� �� IE�.�.� ��.��.Il IFZL � �.]1�I� Tax Map � zi Parcel #,( 0� Subdivision Phase/Section/Lot # # of Sedrooms 3 Applicant: � ci J o� h5dn Location: 2o3q eP s�r , Operation Permit � — System Type (From Table Va): Product (IIIg): v2 This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. � Scale Tax Map: � Parcel #: �_ Septic Tank System Checklist (Type II-I� System Type: � Se tic Tank I itiaUDate State ID& Date: 3-5—/ Z 5` 2 �'''� / Z Capacity: S OcJ� t/ Tee and filter Baffle �/' Vent Riser ' Outlet boot �/' Perm. Mazker 'JistribLtion D-box levels set) Seriai_ Pressure Manifold LPP Notes: ' Pump Tank State ID& Date: z 9�lZ 0 R1S�i NEM.� 4X Bu� Modei_: �,�g� Piggy back plug Hard wired � Alann functionir Mounted on post Above grade (12 Conduit sealed Pressnre Manifold i3uYni�Cr ui ia�s: --�-- Size anci scli: /� / U �� s Pump System Checklist � s- zy-i � y2� �� Contracfed Certified Operator (Type IV +Systems): Notes: NOTIFIED BUILDING INSPECTIONS: Copy of OP J e-mail Date: �l � � 1 � �,_ s � � � �� Il.�a��9.a�.cc��.11. �c��U.11�� Building Additions/ Mobile Home Replacements Tax Map #: 2 I Parcel#: � b Address: �3 �� "�'r � � � Approval Requested for: Mobile Home Replacement � Building Addition ApplicantName: � �t�tSo,^ Address: �1/f-t� Q � � Phone #'s: �D 3� Z�f 3 9 — Permit Located: Yes No Installation Date: / S Design flow: 3�� (gpd) Current Contract with Certified Operator on file (if required): �� Water Supply: � Well Public or Community Wastewater system shows no visual evidence of failure on: Z (date) (Applicant's signature ir site visit is not required) Addition/Replacement Approved r� � �y�✓ ironmental Health Specialist �B'%2 Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 wwwpersoncount .�net A lication� Date: -/ � � O Z , . . Tax flAaq; �k � `�� kmourftPaid: So. � _ ... . _ . : RecEipt�: __� lo ��.'� � .. . P'an�� ._...�.�� _ I�I�IE�.��T . � . . - � �-��- . . . . ��.m� �.�� .�:� . . . apQucknoN r-o�r s�rc�s � SHALL BECOME tNVALID. • 1) PenNt requested by: (� �wne �gent/prospective owner}: C ��%D Home Phone: -�3 � S�`5� /vZ )"- Address: - e� Business Phone: 33[o S 7 �3 Z7 2' Name and address of carne�t ov+mer. � o, l , ......., l, C��-o �f i � 3) Properly D�escri�tion: t.ot size: �_ Tawnsitip: 6�iur N�//Subdivisicn: � Lot�: Directions to the praperty (inciudin ad.names and numbers): �f �1 i" s�.cC � T��fu v .G� ,1� r �� ' � d� � C � 4) Proposed Use and S'iructure Description: answer eact� of the follawing questions: � G�(Q�) a Pro , Existing Type of Stiuucbure: �� Z sTo2 �dth: �v Depth: ,� bj Num�be�or f Bedroams: � Number of oxupants or people fio be erved: � , • c) Basement Yes _, No � Will there be plumbing in the basemeni? d) Gattiage DisposaL• Yes _, No �„ � Waber Supply Type: Priva�e ,� (new _ ar e�asting �, Public� Community _, Spring _ Are arry we1Ls on adjoining property7 Yes _ No _ lf yes. ptease indica�e approximate lac�ton an the siie pfan. 6) Does the property c�ntain previously identifted jurisdic#tonal w�lands? Yes _ No �f PLEASE NOTE THE F�LLOWING: ' 9 A PLAT OF'[1�E PROP��i7'Y OR SITE PL�►At 91/UST HE SUBAai1Ti'E� WITE! THIS APPLICATiON: ➢ PROPERTY LINES AND CORNERS MUST BE C'LFARLY BIARKED. � THE PROPOS� LOCATION OF ALL STRUCTUI�ES NUST BE STAK� OR �ZAGGED. • 9 THE SiTE flAUST BE i�ADiLY ACC�SSiBLE FOR �►PI EVALUATION BY THE HEd�LTH DEPA►i2T'�IE�i't' STAF�. 1• here6y make application #o the Person County Heatth Departrnent foc a si�e evaiva�on for the o�-siie sewage disposai sysbern for the above-descnbed property. i agres that the contents of this aQplication ar�e true and represent the ma�amum fiaaii�es to be placed on the rop riy. i understand ifi the site is aitered o� the intended use changes, the permii shait became invalid.o � � �I � . � ►, / Owner or � �13-0� Date � .�S_ �, �� - PCHo. re+►. �ar�7ro� ��`�� lok �� D4 ��s�� ,(�c� l :�" �y �� J .+J � �� `� .� �--. � ' ` '_'� � I� � � � � ��a��„--t,-„ ��.11 ��L��IL-�� Tax Map #y,�� Parcel # Existing Sewage System Report For: Mobile Home Replacement / �/ Addition Type: �.2l�-b � Requester: � �d �K.S� Home Phone# - v'ZD� 9 T%e S�P�" �a1. Business #�.�i7— 7�,7 x ,h o�o , I�� Original Permit Located: � Water Supply: ,A^,'v�'1-� Septic System Designed For: t� Residential Business Other # Bedrooms 3 # Employees P Other — System Type:�' ��.�'er�.-�. �- � Tank Size: OD Nitrification Line: .' Date Installed: �%"-19- �"� Certified Operator Required: /"� On-site wastewater disposal system shows no visual signs of malfunction on !.2'" 3- D�, Permission is granted � %. �i �== / � • . � i ,� � � � i � � ' �t � t i � Environmental Health Specialist _Q ;%��_�. , ,� � Date: /.�-� - �� '' —� Site Dimensions , ,, Z� � � � � �,,\ ?/ i �. �� l�� - ' � / :` �S • - ' '� 3/ ,\. _ P � � � 2 � �' I lo/ �l �' — � � 8�—� PLANNING/ GUIDE Custom Name: �G� �o /�11'I-S'�� _ �( �ECK�LANS Date: r�/� s'/a � ��.': �.��