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Amn�nt Paid' ___Q�
Re I t : �
i°e�r,n �oun�y �nvironmental
�?�-6 Cou� StreeY
. =toxbor�, NC ?7573
d �,� p ,p.�
F�ealth
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APpLICATIdN FaR SERV(CES .
�F 7'1-1� INFaRMATiQN IN 7HE APPCIC4T10N �OR AN IIUIPROVEMEiVT pERMIT S INICORRECT, FALSIFIED.
CHAiVG�D, OR THE SITE IS ALTER�'D T�lE�I THE �MpROVEMENT PERNIIT ANID AUTHpRi2qT�pN TO
CONRTr�� �rr �y�� � o�� m� , VALI
1) permit roquest�d by: (Owrtsr/agentlprospectiv� owner): dc.%7�rg-�r 1iC/. �S"t�,¢�,J
Home Phane: 3 3L-rS99- 8,,Z8Y Address: 1" 8 0«�c /oo
Business Phone: �/9�3�3-i,s�3! d . �Z7S�
xad,r
2) Name and address of curr�ent owner;
R�+�cL:.- /},S � a��.
3) Property pescription: Lot size: �G Township: o��c�� h�r! Subdivisio�
Directione to the propariy {Includi�g road names and numbers): Sa
c1K.l re o. K� iCi S!f r' o�s`Ja L1a r%e-L
��vl /%E'S !ts r3f�P QIrd�J OK To C /.�,c>., /.,.. ,� �
Lot #
4i F�ropos�d Uss and Structur� Description: answer each of the fntlowing questions: �'
a) Proposed ,�,, Existing Type of Structur�: ��� ��x �n. a W(dth: oZ 8� Depth: % 0�
b) Number of Bedrooms: ,� Number of occupants or people to ba served: _�
c) Ba s e m e n t: Y e s,, N o „� W I I� be p lumbing in the hasement? �7 r9
d) 6ar bage Disposal: Yes _, No
5) Waber SuP�sly Type: Private 'Z (ngw � or exist(nc��, Public Communi
Are an wells on ad'oin�n ---� tY;, Sp�ing _
y 1 9 P�operty? Yes_ No� tf yes, please indicate approximate location on the
�sita plan.
6) Does your propetty contaln previously iden6fied jurisdlctlonal wetlands7 Yes No�,
F EA N� TH FOLL WW •
� A PLAT OF THE PROP��tTY OR SiTE f�LAIV MUST BE SUBMIITEO WITH TH15 �1PPLICA�ION.
➢ PROPERTY LINES AND CORNERS MUST 6E CLEARLY MAW(�D. � �
➢ THE PROPQSED LOCATION OF ALL $7RUCTURES MUST BE STAICED OR IFLAGGED.
s TN6 SITE MUSi' BE READILY ACCESSI�L� FOR AN EllALUATION BY THE HEALTH DEAARTNIEAIT
STAFF.
I hersby make application to the Person County Health Department for a site evaluabon for the on-sit,e sawage dlsposal
system for, the above�described property. I agr�e that the contentg of this application are true and represent the maximum
facilities to be placed on the property. I understa�d if the s�te is altered or the intended use changes, the permit shall
become invalld. �
� w��,
Owner or Legal Representa�ve
, ;:
os_,.._
at
PCHD, r�v. 08127J02
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Applicant: ��
Location: �� � �
0
�
T�x M�� ' • F�rcel �
Subtlivi�s�ion
Fh�s�e Sect�ion Lot x
^� 5sis o
Improvement Permit
Permit Valid for ✓Five Years No Ezpiration �
Type of Facility: �,,.,; New ✓ Addition _ Water Supply i'nfxa�
# of Occupants (� �,-,�.x # of Bedro ms 3 Projected Daily Flow 3�c� g.p.d.
Proposed Wastewater System: Ac���z CZ�'/� r-e��-� ��....� Type:
Proposed Repair: �-cp ��c.z (25,� ,re� �s.�.�.��.,..� Type: � �_
Owner or Legal
Authorized Statf
�-/-�o—er
-O(r,
The issuance of this pernrit by the Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
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. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for SewaQe Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that
the water supply will remain potable.
Authorization to Construc�Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_). �
Proposed Wastewater System: (�c�o�a �� 5 l. �Q�.•c.�-�-.1 _ Type Wastewater Flow 3(�D g.p.d.
New ✓� Repair Expansion (' Soil LT . a�S g.p.d./ ft 2 .
Type of Facility: �{�, �m-•,1, ,`�w � Basement _ Yes x No
/�re - �.,� �.� �,
Wastewater System Requirements �
Tank Size: Septic Tank: {� gal
Pump Tank: � gal
Grease Trap:
�� �
— gal
Drainfield: Total Area: 31 �S sq ft Total Length 33rJ ft Maximum Trench Depth /o�-/y in
Trench Width � ft Minimum Soil Cover: �_ in Minimum Trench Separation: 9 ft
Distribution: Distribution Bog
Specifications:
Authorized State Agent: ��
Permit Expiration Date:
Serial Distribution X Pressure Manifold
�. n
%� c - C v�S� ��.-, �e,P �, �
Date: � - �o-O(,
The type of system permitted is C nventional k Accepted Alternative. I accept the specifcations of the
pernut. �
Owner/Legal Representative: � Date: ���� "� � �
PCHD rev. 11/10/OS
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• Date .
°� sy� �o�o� �,�s�t �pm���contours o�ly. The contrntct+ur must„�lag the systesn�rior to
7seg�inning the instadlatian to srxrure that pr+npergrrtde i.t masntained :
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�aaw-alc-a��natn�a�sa�.tn.� �ae�.�.��a
Sloped To Shed Water
NEMA 4X Simp1ex Contml Panel
4" X 4" Pxessure Treated Post
12" Sappration
Electzical Conduit �
�
!i" Covar • ' � Accras Cov�er• .• , ' . ; � .1 �
� . � _ -�4 i
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. � � � J • : . �• . ,
� �., Openiaz Filled V�iith �}i Siphon Hole ��
Izilet Fmm Septic Tank Portlaxud Cement Gzout �� g��
4" SCH 40 PVC Pipe � C��
Valve
� Sigh Water Alarm Level
' (6" Separatien�
' High Level - Puxr�p On --�_._�_�
;:
T�x M��� � � F��rc�.l #
Suhcilivisioii
Ph�as�e Scct�ion Lot #
Duct SealBoth Cozics�ete Rver '
Endi Of Tha Con�.iit •
�- 24" Mini�uxn
`• •, 6" Sapaxatiott
T�readed Gate Valve ; '
IIxuon . , • ' :i .c;�J' .
. .' � .
4����Portland Coacreta Gzout •
. 's: Ma�tic • - ;
� . h,
z�p co�a � � ' opa� ��a w�tx
. Tie1 Supply �:' poxtlaxid Cazaent Gratt
� L� .. t
4utlet To D'utnbution
.�u,.t�„ 2" SCH40PVC Pipe
Float Wuei ' �
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F10 '� �
�Drawdoafi�a �oleock , p1 at� ...
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. �r � CUP� �R.l2riOV2b18 �•�.
� � F1oat Txee
,�
, Law Lav+al -Pump Off .
r ' ' , Pll2ttp � •
,� Preca�t Concrete Tank 4' Coxicsete ',
�;.; Material Stxex�th y3500 PSn Block ` I .,�.
` �'�-: •� • r . ' • - � '. . � : • , : . . '� � • ' � • � ' •
. /�_ GALLC�N FIT1Ug' TANK
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1�'1',an-rnn-•rnnanan.�an+L-..cnJL ]HLK-.�.11�EIla Owner:
Ta�c Map: AZS Parcel #: ZZ� Date: -����4
Line Tap Tap (Sch) Tap Flow Line Length Flow / foot
# Diameter(in) ( m) (ft)
1 I z �,S
2 �! �
3 �/ � v�
4 '/Z � 5.5' cov . a
5 �/2 5. 5. Co c� . v
G '/Z � �
7
8
9
10
,33o Ft of line x 65 gal. per 100 ft =Zf���� Z�U�U ']00 =�/� gal
75% x z�S gal = 1[. l gal per dose �_ gal per minute (gpm) = Flow Rate
Friction Head
Loss: �I �5 ft per 100 fit of supply line x�_ ft of supply line = 100 =��2i ft
5• Z ft x I.2 =�'J� ft of friction head
Nlanifold Size: 3"�/ " Force Main Size: �_" PVC
Total Dynamic Head =� s ft of Elevation head +'� ft of Pressure head +�• 3 ft of
Friction Head = Z3. 3 TDH
Pump Requirement: 33 GPM @ a 3� 3 ft of Head.
Drawdown: I(, � gal per dose = 2l gal per inch =�_ inch drawdown per dose
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Schedale 40
PVC
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9 mcmc
rm.iz�.
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Manifold Size / # Ta s
nifold Max No. Taps off one side
�ize (Reduce b I/: for ta in both
�/i» ta s '/1' ta s 1�e
2" 4 Z
�» 9 5
4�+ 16 9 `'
6,� 4p+ 21 7Z
� Flo�v er Ta
Si:.e iLlaterial Flotiv GP.bI
;; " Scbed 80 5.5
;�s " Sched 4U 7.1
3/, " Sched 80 1 �.1
' 3; " Sched 40 12..i
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Tax Map .A�� Parcel # a� _ Tovvnship:
Applicant• ' Pa� � �0 �-. r.� c�1.r--
Subdivision. Lot # .
Location:�G� � z�} o-,ro . ��, �„� �i � n o„ Ul,�er (R,�� ,� �
SO ���V /� �6 � . .
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��1@ O�'�a�fl' �lld��D��: �jI11d1YI�.ild1
�Ci�BUY'et�8l1�:
Site Approved By:
Grauting Approved By: �
Well Lag. �
Pump Tag: •
Weil Tag:
Air Vent: � �
Hoae Bi�• �
Caeing F%igh� �
Cancrete Slab: � �
COID711Iltll� Pll�]I1C
Liner. .
' 'Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Well Driller: .
�Vell Approved by: � - Date•,
�-**9ee.��ched Sfte Slc�tch*=*�
WeiL9 must be 10 feet frflm property lines.
Wells must be 100 feet from septic systems.
Wells must be at least ZS fee# from any building fo dation.
Other canditions: ��1a.�_ �,�c Sl�a a-� �-. e��.,
PC� rev 01/27I0�