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APPI.ICATIOM FOR SERVIC�S
, , . ;.Secu�:ces:l�eq�l��d ,.� . :,;.: .:
>.
vements Permit (Recarded Lot) -�3200.00 ❑ Wep Permit (fiew/Replacamertt) - S2
uements Aermit - S15D.00 t] Cortstruction Authorirat�an for Septic
� Hama Repi�cemertflAddition) $'150.oa�oa.00
E�dsting
- $75.00
�3) Pe��r�ih ret�uested b�; (Own�rlagen�lpncspeciive awner): ��� _ST
Horr;�; �hane: �' Address: 3�0 � li
Bu�,�ness Phane:` �" ^ �° `S
:2) MakriE� and a�dcfress o� curren� owner: ,��ir1f
3} Pr�c�ls�,rty Desc�ap�ian: La# size: cre.. Township: ' e �11
O94'i�ciians to:th� praperty (In`ciuding road njam�s and numbersp� �
-�i ✓YI 1' Jl� �. .: /J � /Y l� �% /.S� i'� ji_ n %/� 1�. !
�i�Y'1n
s�v� /le� �.ot � % �
4) Prupnsed Us� �a�n Sfruc$ure Uesariptt�n: a�swer ach of the foilowing questions:
a} ��roposed ✓; E�cisting _r,,: Type of_5tructure: ��s id���i��4 � Width: Depth:�
b) t�lumber of Hedrooms: _� Number of occupants or people to be served:
c} B�asement: Yes,�r,; R10 � WiU there be plumbing in the basement?
d1 �ar�age i3isposal: Yes , No _,�.,
5) lA��u4or Su�sply Ty�e: Private �{new � or axisting____}, Pubiic_,, Community_, Spring ,^
Are any wetis on adjnining property? Yes� No _„_ lf yes, please indicate approximate locatiori on the
'site pian:.
6) i��ac� your �ro�erty �ontaln prevBausfy Istant�fed �u�asdlctional weitands? Yes_ No� 1/'
Pl.�i�E Yd��'E'3Ti� fit3LLt�WING: � ,
��► PLd17 C3� T�E PROP�RT`f OR SITE PLAPI MUST SE SUB{Vi1TTEl7 W1T4�! THI5 �►PPIflCATiON.
➢��'ROPERTI LlNES:aW� CORNERS MUSTBE CLEARLY MARKED. ,
9 1'NE P�ZOf�C3S�Q LOCATIC�M OF �1LL STRUCTURES MUST BE STA�D OR FLAGG�3�.
5� .�'iiE Si7� �itl�T BE �DtL`! A�CCESSIBLE FOR AN EVALlJAT10M BY iHE �iEALTH DEPARTiiNE�IT
:►TAFF.
I her�rr;� make applicatiort to the Persnn County Health Department far a site evalua�on for the on-site sewage disposai
sys#e�~� fc�r the abave�iescribed property. t agres that the contents of this apQlicatIon are true and represent the maximum
facititiE.:� to be pfa�ed �an the property. l understand if the site is aitered or the intended use ci�anges, the permit shail
oecorri�: nvaiid: ) �''
or Lagak
g, �� os
Date
PCND, rev. 06127102
� �--��� � � �J��� �i1/� �� �2� �°�' � 2tf3
��. 'Y' j'-� (� �jj� o 0 o c7 ��-r� L��l�Y�"t
-, -,� u✓ � �� Jl � �,�.,�,�� I
;� �_.����,rn �rr-n-�, ���.��.� 1L 1L��.��� � � � [�'�• U G � ` �-
Ymprovement �ermit �
��rnnit Vaiid %r � �'ive Years No �apiration �'
Type of Facility: 38� ��� New � Addition Water Suppiy �
# of Occupants✓�� 1� # of B drooms �_ Projecteri Daily Flow 3� g.p.d. ,.�} �,�
Proposed Wastewater System: 'kv • � Type: `l--µ'
Proposed Repair: � Type:
Permit Conditions: �� �t c� S�� �
Owner or Legal Representa.tive
Authorized State Agent:
Date: 3 —4 �o
The issuance of this permit by the Health Department in does not guarantee the issuaace of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Plannmg and Zoning and Building Inspections requirements are met This
Improveuient 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 ownerstup of the property. This permit was issued in compliance with the provisions of the North Caralina
`Laws and Rules for Sewage Treadnent atid Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmeutal Health Specialist warrants that the septic tank system wi11 continue to function satisfactonly in the future or'that
the water supply will remain potable. �
Authorization to �onstruci Wastewater System (Reqnired for �uilding Permit)
* See site plan and ada�itional attachments (_J.
Proposed Wastewater System: C�M n l.D`'Ll%�E'i"�ai't-� ( Type� � Wastewater Flow 36�g.p.d.
New � Repair Expansion _ Soil LTAYt: g.p.dJ ft 2
Type ofFacility: , ��'3��t'�'L°�• Basement_Yes No
�Vastewatea� Systean Require�ents
'�ank Size: Se�tic Tank: �f��0 gai Pnmp Tank: �C��gal Grease Trap: gai
�rainfield: Total Area: �zd� sq ft Total Y.ength �d� ft lYlla�mum Trench Depth 2� in
Trench Width � ft Minimnm Soi1 Cover: 1� in Minimnm Trencli Separation: ( ft�-�•
3)istribation: Distribntion Bog
specifications• 5.�� ' p �l Nr►�' '�
Authorized State AgQnt:
Permit Exp:
Sen �istribn ' n
�; ;��� �<
�
The type of system pernutted is � Conventional
P��
Owne�/i,eg�l �epresentative:
Accepted
� Pressnre Manifold
Date: �- "' � 3'�
�
Alternative. I accept the specifications of the
Date:
pCHD rev. 11/10/05
A
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N�atn.e QS Tax Ma.p #� a l� Parcel #���3
Sub ''on �2t� G� �rn^ • Section/Lot# � Z-
r� c/11-� � � � �'-a-3--0 �
Authorized Srate Agent ' Date .
�• Syat�i com�ionents �r�saent ap, pr+oximate�ron�aurs o�ly. The contr�tctnr nwst,�a,g tha system prior in
Jsegitaning the installaizon to irusure �iaf propergrtrde is maintained ;
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NEMA 4X Simplex Contxol Panel .
+4" X 4" Pressnse Treated Post �,i ;
Sloped To Shed Wataz la' Sep�ration �
` Electrical Conduit --
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6" Covex • ' � Acce» Cover• � , •• ' : ; ' .1_ � , ; I,
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. �,, Opex�in= Filled With . Anti Siphon Hole' `
Inlet F:om Sapiic Tutk Poxtlaxud Cemex�t Gxout �� g��
4" SCH 40 PVC Pipa � �
Check
� � Valva
High Water Alarm Lev�l
(6" Sepazation�
' Hi;h Level - Pump Ox -�.�,�
� � « +�VaporLock
'• � Hola ..
. � Drxvrdwm �Up ��
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LowL�vel-RunpOfi ---�""'
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T�:�x Nl�i�� F� � � F:�rcc�l # —
5ul�ci'ivi�sioi� � • � �
Fh•��s�e Sr.�ct+ion Lat #
D�ut Saal Both
Exd� Of Tlu Coz�it
-� 24" Mininn�m —;
�• •� .-•, .•.
Tlueadad G�te Vdve
Zip Co
Tu�
' Psecut Cozticrete Taalc 4" Conezet�
' • � ;.; Material Strength �3500 PS Hlock
� '+`.: . .• � : ; • • ' - _ ' . . .% ' , • . . '�
Cozicrate Rve:
• �� 6" Saparation
'�.-Poxtluid Concr�ta Criaut
_ • i �i1t]C • ' : .
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Supply � • ' � Opaning Fillad With
i� � ; , Portland Gxunt Gmnt
Outlet To Dutn'bution
2" SCH40POC Piy.
' F]oat Wixe� . � �
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F7oat� .�;
�Removabk �•�.
Float Trea , ,
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�E�.-��,.,, ,.�,. ���.11. 1HL�,�.11��. Owner. �
Tax Map: �" � Parcel #: 3 Date: 3� Co
I�ine �'ap Ta� (Scli) Tap �'!o� Line I��ngth �'1ow J�oot
# �iameier(in) ( m) -; ft)
� c� v � c9v � d�
2 � c� � W
3 2 � �� v�
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5
6
7
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9 �
10 �
P90 ft of line x 65 er 100 ft=�� ��°"`'"—�1 ; 100 =a� � gal
75% x �ga1= � gal per dose �� gal per minute (gpm) = k'low I�ate
]E'riction Head
Loss: �� ft per 100 ft of supply line x l� ft of supply. line = 100 =�� Z ft
�f � ft x 1.2 =_� ft of friction head �.
Manifold Size: ��_" I+'orce Main Size: 2" PVC
Total Dynamic �[ead =�ft of Elevation head +� ft of Pressure head +�� �ft of
Fricrion Head = 20. � TDH
Pump Requirea��,nts �%� GPM @-�• � of H
���Q�; L Y per dose � 21 gal per inch =� inch drawdown per dose
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u%ld M�c Na Tapa off aoe side
;i� nca b'h inr ta ' both
�i» �.» tRPs �»
Z". 4 -.
3" 9 �
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �
Applicant:
Subdivision:
Location:
# o� �� Township: :
�
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****
Lot #
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:
PCHD rev O1/27/04