A29 232A��siication Date: `"��l �`d� 2 p �33 �}e ��J �
�mount �aid: � �QQ�,jL-� 5�
Rec�ipt �: �
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l�PP�1CATlOfd FOR SEiZVICES
3ax iUlao �:
Parcal �•
IF THE INFOiaMATIOM IN i�iE APPLIC�4TIOi�! F�9� �Rl IflAP4��!lEi�IENT P�ERIlflli' IS INCDi�RE�T. FALSIFaEL1,
CHA�GE� OR TFIE SIT� !S ALTERED. i3�EA! T➢-aE I�PR�b'E3�iENT P�RiViIT AND �,UiH�RiZ�iTlOft! Tt�
COi11STi�UCT SHALL BE�OAAE IiVVALID. -
�) Permit rec�u�ted by: (Owrnerlagent/prospeciive owrner): /��
Home Phone: � Address: 3�0 /la
Business Phone: - D o s
, 2) Name antl address of ctarrent owrner: ��i'I �
3) Praperty Desc�aptoon: Lot size: cr� Township: 'Ye ��l
Directions to the property (Including road names and numbers): �
� n,i)�S �e�h�i di.Sl�n nin �
�'�}Y�1
�u; /)e� Lot #�
4) �ro�osed Use an S�e�.�cture Description: answer�act� of the following questions:
a) Proposed _, Exisfing ; Type of Structure: �S %e�P�i�i�i4-) Width: Depth:
b) Number of Bedrooms: � Number of occupants or people to be served:
c) Basement Yes , No Will there be piumbing in the basement?
d) �arbage Disposal: Yes No _ '
5) lf�/ater Supply Type: Private �(new _ or existing�, Public� Community� , Spring _
Are any wells on adjoining property? Yes_ No _ If yes, piease indicate approximate location on the
�site pian.
6) Does your pro�eety ��ntain prev6ously identified jur�sdic'tional wet6ancls? Yes_ i�o i/�
PL�SE �OTE THE FOLLOVIlING:
9� PLo'�T OF 'i�lE �ROPE3iTY OR SIiE PLA�1 i1�USi �E SUBMI'q'i'E�D Wlii i'HIS �►PPLIC�►T10N.
➢ PROPERTY LINES AND CORPJERS MUST BE CL�RLY MARKED. �, �
9 T9-!E PROPOS�D LOCATIO(d OF AL�. STRUC'�'URES flflUST 8E ST�►FC�D OR FLAGG�E�.
9 TiiE SITE MUST �IE 3ZEADILY ACCESSIBL� �OR j4i� EVALUATI�N �� ZFiE HE�►LTFB B�EPARTV�iE�IT
SiAFF.
I hereby make applicatio�t to the Person County Health Department for a siie evaluation for the on-siie sewage disposal
system for the above-described property. I agres that the contents of this appiication are true and represent the ma;cimum
facilities to be piaced on the property. I understand ifi the site is aitered or the intended use changes, the permii shall
become invalid. % e'
or L2gal
g, i� os
Date
PCND, rev. 061271�2
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Applicant:
/
T�x Mra�� � �rc�e:l � .
► � ,
Subdiivi�s�ian . ,�
ha:s�e Sect�ion'Lat �
Improvement Permit �
�ermit Valid fo� � ve '� s_ No �zpiration
Type of Faciliiy: � � • New �Addition �Vater Supp�y _ (��
# of Occupants� e�,� # Bedrooms � Projected Daily Flow `� �v g.p.d. -}�,,
Proposed Wastewater System: � Type: �tL �
Proposed Repair: ,/iiAM�P G �W Type: �
Permit Conditions:
Owner or Legal Represe
Authorized State Agent:
Date: -- �
The issuance of this peanit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are meL This
Improvement Permit i� subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a ciiange in ownership of the property. This permit was issued in compliance with the provisions of ttie North Carolina
`Zaws and Rules for Sewa�e Treutment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmeutal Health Specialist warrants that the septic tank system will continue to function satisfartor�7y in the future or�that
the water supply will remain�potabie. �
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_�.
Proposed Wastewater System: �. Type �b� Wastewater Flow ��.p.d.
New � Repair Expansio Soil LTAR: ��i.� g.p.dJ ft 2
Type of Facility: T ��� Basement _ Yes '� No
. �Vastewatea� System Iiequireu�ents
'�ank Size: Septic'Tank: � gai Pnmp Tank: l('�� gal Grease �rap:
�rainfield:'i'otal Area: %3� sq ft Total I,ength ��� ft 1VIa�ffium Trench I3epth
g�
t g in
Trench �idth 3 ft t�inimnm Soi� Cover. � in Minimnm Trencli Separal3on: � ft �• C•
�istribation: �istribntion �oa Serial Distribniion k Pressnre Manifold
Specifications: �� � St 0�2 S ��C.' �
Authorized State Agent: '�/'�' Date: "' 2�'�''
Permit Expiration Date: � -a0 -�
The type of system permitted is � Conventional Accepted Alterna.tive. I accept the spe�ifications of the
permit.
Owne�/�,agal �8epresentative: Date:
' pCHD rev. 11/10/OS
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Authouzed Srate Ageat D� •
5ysrem compaaeass reprrsearapp�arr canmurs valp. The roarracarmusr�agr6e system pacrr tn beg�mg ffie msrnII�aa m
%••Q,•,,• sharprapa�rrdeira�a�taiaed. �
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WELL PERMIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �
Applicant: _
5ubdivision:
Lacation:
Type of Water Supply: '�Individual _ Community
Requirements:
Site Approved By:
Grouting Approved By:
Well Log:
Pump Tag:
Well Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Well Approved by:
****See Attached Site Sketch****
1..ot �# t
Public
Liner:
Installed by:
Depth set: _
Grouted:
Date:
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:
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PCHD rev O1/27/04
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�aa�v-a�c-as��a.�mm �a.a�m� g�a�.m.���►.
NEMA 4X Simplex Control Panel .
4" X 4" Pressara Treated
. Sloped To Shed Wafer 12" Sep�ration
\ Electxical Coxuluit -
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b" Covax • ' Acces� Cover. � • • . ; 1 , �
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, �,, Openin= Filled With . Anti Siphon Hole �
InlatFmmSapticTattk PortlandCe:nentGxaut ��g� �
+1" SCH 40 PVC Pipa � ' '
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T��x M�t{� P,tr�:-c�l #
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Sul�ct:ivision
Flra�s�c Sc�ct+ioi� Lot #
Duct SaalBoth
End� Of 11u Cox�rit
�- 24" Minix�aiat -
Thre�dad Gate 9alve I;
Llnion / � r"1
Zip Cord
T'u� 1
Check .�.N;
' . , . Valve �
High Water Alarm Lav�l
(6" Sepuation�
„ , ' Hish Laval - Pump On
' � � i� fiVapoxLock ��
!• � �� Drawdawst Hola • � 1
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. Low L�val -Puxnp Ofi
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' P:eca�t Coixrete Taak ' 4" Conezrta
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' • � ;.; Matezial Stxength }3500 PS H1ock
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Concmta R'vez
b" Sapuation
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'�„_..�Po�tLxudConcrete Cnoi�t
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. � Opani� Fillad With
upply Yortlu�d Camant Grout
,ine • • '
Outlat To Di�tnbuiion
2" SCH40P`TC Pipa
�� P1oat Wire� .' �
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F7oat� �.�:
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F7uat Tre� , ,
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Tax Map: � Parcel #: .23� Date: ?�-� (�
L,ine Tap Tap (Scl�} Tap �'lopv Line i�ngth �"1ow i foot
# Diameter(ua) ( m) - :. ft)
1 � z � �v S• S' �'sa � n ��-
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5 ' L �Ec� �� l .n'�
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8
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10 �
��n ft of line x 65 gal. per 100 ft=Z ��� '�� ; 100 ��� gal
75 °Io x=� ga1= 2/ S gal per dose � gal per minute (gpm) = k'low IPate
Friction Head
Loss: Z• � ft per 100 ft of s�ply line x~�� ft of snpply. line =100 =�- s ft
• S ft x 1.2 =�(� ft of fricrion head �.
Manifold Size: �_ '` _" �orce Main Size: 2" PVC
T o t a l D y n a m i c � e a d = 1� ft o f E l e v a t i o n h e a d + y f t o f P r e s s u r e h e a d +�� ft o f
Friction Head = Z � TDH
Pump Requirement: 3? GPM @� 3• ft of Head � �
Drawdown: 2�>al�ose � 21 gal per inch =•� inch drawdown per dose
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Size iLlcuerial Flaw G?�!
l.�.'• Sched 80 �.S
. L,,• Scned40 i_1
3, :• �ched 80 10,1
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