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A29 199J � Application Date: 3 `1�-�� Amount Paid: l,�o . o D Receipt #: 2 � 2 F�'�- � � 37ad d °% P �.,� s ' � � �- �� Person CountY Heaith Department Environmental Health Section . APPLICATION FOR SERVICES Tax Map #• � �� Parcel #: ��� IF THE INFORMATiON IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS FALSIFIED. CHANGED, OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORiZATiON TO CONSTRUCT SHALL BECOME INVAUD. i) Permit requested by: (OwnedagenUprospective owne�): E%��'+�+ ���� `�- Home Phone: �jq 5G �- �/7'�? Address: �o LJ. r � . Business Phone: 9/9• 3c�-zz�y in, eha�,., �, v� c,• .�r� 2) Name and address of current owner. t�i%wre.� U�'�' �- 30�. Lt�� ��.��iE��.., �. v►.,�b� �,.,�� �e • �� �r � _ 3 -3 3) Property Description: �ot size: �� Township: ��. d%11 Oi�ections to the aroaertv pncludina road names and numbers): _�� � r$• 4) Proposed Use and Structure Description: answer each ofthe foilawing questions: a) Proposed L�t!Existing � , b) Stick Built �, Modular �ingle Wide �, Doubie Wide f� c) Numbe� of Bedrooms: �, d) Number of occupants or people to be served: e) Basement: Yes �. No �'Ifi'yes, # of basement fixtures: fl Garbage Disposal: Yes 0, No L� g) Oimensions of Proposed SUucture: Width: �, Depth: ,,�� 5� Water Suppiy Type: Private�9'�new � or existing a), Public �. Commun'rty �, Spring � Are any wells on adjoining property? Yes Q No �-Ff'yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) �Conventional Modified Converttional _ Altemative innovative Other (specify): CLEARLY STAKE ALL CORNERS AND UNES OF TNE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SRE PLAN TO THIS APPUCATION I hereby make application to the Person County Health Depa�tment for a site evaluation for the on-site sawage disposal system for the above-described property. 1 agree that the contents of this application are true and represent the maximum faalities to be placed on the property. I understand if the site is altered or the intended use ctianges, the permit shall became invalid. i undecstand that as appiicant, I am responsibte fo� identifying and marlcing property lines� camers and making the site accessible for the personnei of the Person County Heatth Department to condud them evaluations. I understand that I am responsible for nofiiying the Heaith Department if my property contains any wetlands as desigcrated by the Army Corps of Engineers. � 3i��o� � •"-�--�/ % ��-�-�-•� Owner or Legal Representative Date PCHO, rev. 10/12J99 y • �\��t,l f ���� �� V �._... � � � �� � � ., I� �.� a � � �. � � � �.�►. ]1 I�3I � .�.Il �1� Applican� Location: T��x M�F� : - Parc�el # ' ` S�uhcl'ivi�sion ' Fh��se SecMt�ion Lot # Improvement Permit Permit Valid for �ive Years No Ezpiration Type of Facility: 2eS�c�ev�c� New ✓Addition # of Occupants �.K• # of edrooms 3 Pro ected Daily Flow 3 Proposed Wastewate� System� u� '' ��o�� c_vf �•-�•� �i(pSSUV1� I�ta �.ia Proposed Repair: Permit Conditions: Owner or Legal Authorized Statf �� « �� Water Supply We �� _ g.p.d. � � Type: � Type: � . � � o���a�i�J�.� a,o._a �0 r�►i�. �� Date: Date: J- 3/- 0 0- 'The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. Thls Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. Thts permit was issued !n compliance wtth the provisions of the North Carollna `Laws and Rules for Sewage Treatment and Disposal S stems' (15A NCAC 18A .1900). � Authorization to Construct Wastewater System �Required for Building Permit) * See site plan and additional attachments (c1 � j. � Proposed Wastewater System:Piac�� :I.�,,,o�a�'v` `�Pn'ssu,-� �hi���Type Wastewater Flow .3�D g.p.d. New � Repair E pansion _ Soil LTAR: �, a �,� g.p.d./ ft 2 Type of Facility: �S ���.�P Basement _ Yes �/No Wastewater System Requirements Tank Size: Septic Tank: (000 gal Pump Tank: (Oda gal Grease Trap: -- gal a« c-�.wr� � Drainfield: Total Area: 9`�o sq ft Total Length 33C� ft Trench Width � ft Minimum Soil Cover: � in Distribution: Distribution Box Serial Distribution Specifications: � /'Q a /�i`�ona % � � 1 � v�� �eQ li � r� Authorized State Agent: Permit Ext Date: /-- '3 /� d The type of system permitted is Conventional the petmit. - Owner/Legal Representative: � Maximum Trench Depth �� in � S��P .c �%1�, Minimum Trench Separation: �I ft �essure Manifold r i�h l► %'� G' Yi►�n ��e ��( 4[ �'Z°� � Date: �- �i %- O � Innovative Alternative. I accept the specifications of Operation Permit Date: 5ystem Type (in accordance with Table Va) � The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. Issuance of this permit does not guarantee that the wastewater system will function properly for any given period of time. Authorized State Agent: Date: PCHD rev. O1/23/02 'l . .• uiac.uiviu�.uuu a� www.uGil.eIlT.SiiIiB.IlC.i1S 'Fitting-to allow fo� connacfing slear pressure monitoring tube Qezve fube In bottom of vault) Alwninum oe #eei � shoebox-type covers with i�sndles (150 lbs. each, muc.) Support straps I oe 6ars • f�lanifold supports �� '�' • • � '�' `''i'J level manifold installation Page 1 0� 2 �Cravel pIt for iMernal.drain dischuse � � 1� �_ Vl �.. �%� X ��, � � S �l � Proi�e View of Pressure Manifold for Slop�ng S�te Installation (not to scale) - _ - Tap - dired thresd or sed,�De ' Qe�m�d (i!'tapPedw�mele adaptor� ts�m Presssu�s hesd eheclt ih�st� svith msirle ovatl,l �-- �Infemalve�il2 d=sin Msnifold vau$ o 0 0 o n o 0 0 Txue-�mionballvalve (ball valve with tao ditcoaoed �ioas) � 1 1 1 1 1 1��� �+iy � Obse:vsdian port (tee wlth e�es►simt to d:a�nifaes et min. 1.0% slope �roogldto gracie; with xrstrovabk cap) Plan View of ]Pressure Manifold for Slop�ng Site Installaiion (not to scale) http://www.deh.enr.state.nc.us/oww/LOSWW/manifolds.htm 10/18/00 ttEMA 4B Sanplau Coat�lP�mr�1 x � n� D�et SaalHoth 4" X�" P�xsr Tzeated Post I j F•xds Of The Coad�t CO�te &'v� S7opedTo Shed Water 12" Sepasatma 2�' ffii�"r � � Electacd Co�dmt , . . � . -• , . . • 6" Sapuatioa Tlsaadd Gate Yaiva . • •r � , �II1O31 ' �r��.0r�• S" Cover • ' � Acce» Cover• • . : � 1 ' �,r,r-Po:t]axid Coac:at� Cnont I.' •• : i ~ ~ •. . ' �y , l � i� �a3St3C • ' . • '•� `Opeaia= Pilled With . . .. , . • - _ . , �P Coxd '•' . �• . Opa�g Fi7led With � � r.• A�s Siphott Hobn Ties SIIIIPiP' •,ti Poztlu►d Gmat�t Gtont .. In]et Fxom Septie Tazrk oztlaad Gsneat Gxoat �� g� . �° Ont1�t To D�ioa +{" SCH 4D PF�C Pip• "'� �� Z" SCH40P�C Pipe Nyion 9alvs � P]oat �V'ue� ` : Higk�, Wat'r Lla:m Lawi � � � (6' SeIIarafmn) � • „. , H�S Le*�1- P�Q Oa ; ••. ' � % �� +�Yapos Loek . F7oatt '. �: • � 8 Hok • , •• � � CIIP �l r�..Ramovabla • • � .; � �, � FJo:t Ts�e , . I.aw Laval-P�anp Q�' • . . p�p ' • — �;•� � ' :� ' :: ' P�cait Cozx:ete Taak 4' �O�t° � PUHP RA?ING � . '.; S s•3�0 P � � � .�; . � ,., . . , . • . . . , � • , l - Pump Must Be Rated 7o Deliver �'4: • • • • ' • '` ti • �� Gallons Per Hinute ' ' Against �Z, Feet Of Tota� ,�poo GAI�L(�lYFIT1WB' TA1�T.K Oyctamic Head (IDH) . � ...... ;FS �:essa_? :rzate4 pes� •�* aqc:v3:ee� l NBll� 4% . ..� �nclosuce � idater tiqht , + carrosion ;stall ? cireuit �esistant � .scannect soitcb � pauel does not � � ;Ye a dead frnnt : �..._::, � �h �anaal uiscannec�. .,.. : � � ote: A 6r:aker daes .._ . i. coIlSLitate d `+. , \ SC0442CC� > 1," t0 fiaish grade anap �upplp circni. � �IdI3 C_IC11t . iat�r 'ight �eal � 3ydrauli;. cene�t� • _ _ -� Schedule �0 ?YC S u p n 1 y '— r_:_`— ?iq�vback Pluq and Receptacle — �.� 4z4 ptessare t:eated ��� past ar eqnivalent �8�6 �� 3n�=°$°tP �{atet tig°t . } cattasioa resistaat ' � Z� 31Il11IIi uas 'iqtit Condnit >Ii' to finis6 grade , paip supplq circait alara contral � �. �ater fiq�t Seal Hydranlic Ceaent ' • -- ' Harness R:cess Cards — — ._. � � Sctiednle 40 'YC • �aPPt7 Simplex Control Panel Wit:� Huilt In Alarm Hote: This is nat a Yiring diaqraa! Caasnit an glectrician! -� Duct Seal �eceptac�e snst be satar :ated �or+-raltaye aiarn ' coanectian Oact Sea� _� ��� �dCl(I�Q 5�-=�5 3araess Szc�s� :�:i� �— :•6e �:a:a �cs� 5e aoaared i� :he f'_a:�a�: liviaq �;ea �3� �he �YP j'_:2Q ( 30L LII i..''.? craxi space qaraqe o: aude= a aobile hone; �he race� aust 5e aad:�i: and �isi5le �n spstzY :sers Lac�iaq straps • ' 0 ���;sf. �I��$��� �_ ������ � ��a-�,r„ „�-„ ,8�.��.11 IHI��.Il�]�. Name ��w�.ec- ���s Subdivision R�'ev►l(e ; e Autho ' ed Sta.te Agent SITE SKETCH Ta.g Map # A-Z� Parcel #! q 9 Section/Lot# � � 1�3(�02- Date System components represent upproximate �contours only. The contructor must, flag the system prior to�\ beginning the installation to insure that propergrade is maintained . � i �3a' t� 3 r Pu� T.ncva�H2 ``�/IpvL°sSa � tN�nt-�i��e� �e�r�G �� S�G�- r� �s ��;�,u�. r���� �,�� �� do�h%.`l� s,�e � �ire�c� _ �d 1��o�i TrOn�t� .Sc� i�( (...� JC'('�' �,�( u ��� �J � fre l��z+ �,�e%� l�'�°a . � ,� 5��. l� af �r�»»r'er �2 .� ��o � �K� �-h.^7o k r � pr ��;� ��1� `� � L�` c(Y ' � . . 1 (�'� P a3 � SC�C: ���'J��/ � � � �..�"� a{;�G �hNO� �lQ �r�-j' � r ss�re , �ti �I Q�p��� �� �� 1 � J Keep s���Y 1�� =s"' �-� , � r� trf !� �.c t�u wv.+.v r.� ��r � F� y ,4,-e�, SpG � c o� PGHD, rev. 09/12/Ol pERSON COUPITY ENVIR�NMEH�iTAL HEAL'TH � PLF�+SE SE� A�i'ACHED PLAiN F{�R 1NEl..L StTE LAYOUT T��� �2� �. I°l�1 � , , s �i � rsl � � � � . � � �. � ���-= ����t����C�c��� Tvt�e of Water Suaaiv: Reauirements: Well Permit �dividuai _ Community ____ Pubiic S'ite Approved by �D 2 Grouuiing proved by � . . Weil Log ai�9 Weil Ta � � Air Vent � Hose B� - � � Concrete Slab � Well Driller.� — . Well Approved By: � Date: ���e'�� **See Attached S'rt,e Sket,ch'""' Well� must be 10 feet from property lines. ..1� jt ells must be 100 feet from septic systems. Welis must be "at least 25 feet from a►nY building foundation. Other conditions: . q 0 PCHa, rev. i1129199 ��� S ���� �� D�Uc� �D � ��.?u - '-' "' � � �t >�1-�:`fT_ �J �! � � � ���� 0 0 0 �����������.a ���.��� �o � .� �-r � -�� Well Log Owner: ,�',�, ��f's Location• o%' � ��r� /����'�% Subdivision: �,�,:,. u; i/� �Cir�/c ___ Lot # Tax Map ParceT # � Well Construction Distance From nearest Property Line (Minimum 10 fest) Distance from Septic System (Minimum 60 feet) Total Depth: 1 yv ft Yield: L' GPM Static Water Level: a �� ft Water Bearing Zones: DepttLSj� ft�� ft�[ ���ft ft Casing: i Depth: From � to �� ft. Diameter: � in Type: Galvanized Steel I,� Weight: Thicl�ess: .�2� Height above Grouncl: in Drive Shoe: �%Yes No Any problems encountered while setting casing? _ If "yes" give reason: Grout: Neat: Sand/Cement Annular Space Width Method of Grout: Pumped _ Yes Concrete GraveUCement inches Water in Annular Space Yes Pressure Poured Depth Materials Used: No. Bags Portland cement Weight of 1 Bag Pounds If mixture (sand, gravel, cuttings) — Ratio to ID plates: Yes _ No 4 x 4 slab _ Yes _ No No _ No to Ft Drilling Log � Location Drawing From To Formation !r} 4 r��r . : -1 .- o � ,- �o �,; L � 1 �� �� ° i( �' D . �j2��� I�G��� �` ��1� � �or� �� I hereby certify that the above informarion is coirect and at this well was constructed in accordance with regulations. set forth by the Person County Health ep / nt. � Signature of Contractor C� ID# �� Date ��---�>'--4�- PCHD rev O1/16/02 Person County Health Departme�t �`'� (� Environmental Heaith Section (�1(� Tax Map #: 1"1 �-'"1 Parcel #: I 1 1 Zoning: Township: � � �'� � � �� _ Subdivision: � C��2J ��,�2 l" �(��- Section: —, Applicant: ��1 ►rYl� �� )�S Location• I ) I �� � � Lot: �_ Operation Permit System Type (In Accordance With Table Va): THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLlCABLE NORTH CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL, AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION AUTHORI TION. 'o�/ -� � Authorized State gent Date PCHD, rev. 10/12199 PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT . Z-z�- � 2 � Date of Inspection System Installation Date Type ��IJ�'r t- Property Address 2� 19� Tax Map Parcel # Instructions: Check yes or no for appropriate items and explain in space provided for remazks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids: Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? Inches of solids(pump/dose tank): Elapsed time readings ? Counter readings ? Drawdown rate: YES / NO ❑ � ❑ N ❑ / ❑ ❑ / ❑� : � �■ DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?❑ Surface water effectively diverted ? � Diversions/swales properly maintained ? ❑ Vegetative cover maintained ? ❑ Protected from traffic/unauthorized uses ? Distribution devices in good condition ? Field free of settled or low areas ? / / / / / / / / °o ❑ ❑ ❑ PRESSURE DISTRIBUTION SYSTEM: Turnups/cleanouts/valves/taps intact & � accessible 7 � ❑ Pressure head properly adjusted ? ❑ �❑ I�A COMPLIANCE: Compliant Non-compliant Needs Maintenance ADDITIONAL COMMENTS: b L'� ,,.�,'. � Q [� ■ ■ ■' REMARKS c -E'a�K na�' �C�e55i ��e � PNn, -�'ay�i� nci�' aCc255�b�� I P `-� -�azen u C�- Ue. � � t�aY� � � b61�s v2o �'v2 Cover m�i�1%air►�d �