A29 255��� s� ���.���
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I���-ua-���„-,f-„ «��.��.11 1L--3L��.I1�1�
Applicant:
Location:
,
T�x Map � Farcel � �
Su�bdlivis�ion .,� �, �� .,. !.
Fh�s�e Sect�ion Lot #
— Improvement Per�nit
Permit Valid for -, ive Years �No E�piration
Type of Facility: ��c New ✓ Addition Water Supply __�
# of Occupants # of Bedrooms ,3 Projected Daily Flow 3(D g.p.d.
Proposed Wastewater System: _�'Ct,o� ��/�r�,,�o � Type: Ti
Proposed Repair: �; �� cu/r���,,ro Type:
Permit Conditions:
Owner or Legal Representative
Authorized State Agent: �
Date: / �Z� ` - �
Date: r
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 aze 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
Zaws and Rules for Sewa,�e Treatment and Disnosal 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 Const�uct �Vastewater System (Required for Building Perffiit)
* See site plan and additional attachments (�. ?�'l'�LL
Pro osed Wastewater S stem: .r��ta� /��� D Type ��q,. Wastewater Flow .,�D g.p.d.
New � Repair y E ansion�^����— Soil LTAR�� •$ g-p-d./ ft 2
Type of Facility: _� � Basement _ Yes �/No
Wastewater System Requirements
Tank Size: Septic Tank: lOoo gal Pump Tank: �gal Grease Trap: gal
Drainfield: Total Area: DO sq ft Total Length 3a� ft Ma�mum Trench Depth Zo in
Trench Width �_ ft Minimum Soil Cover: ( in Minimum Trench Separation: �_ ft
Distribution: Distribution Box Serial Distribution X Pressure Manifold
Specifications: 3 Gin/�.� v /G10 ' —
Anthorized State Agent: ��� �J/�ii./� Date: _
Pernut Expiration Date: � ��� ��1 �
The type of system permitted is Conventional c Acce ed Alternative. I accept the specifications of the
pemut. ` /
Owner/Legal Representative: / ct C� � Date: ?� 2�` ��
PCHD rev. 11/10/OS
JZ1
�c
�
�
�
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V.. = � j j� . 'ti/ � ��� J1
� �
ax M�p � ' arc
Subdlivision = J I � �
Ph�se Sect.ion; ot # �
�
�'�R�ba-�mL3t�a��.��.11 ����.1t.ZWCa.
Applicant: � ��� � �
Locaiion:
.. n S. .
�
. ������� ����t
�
. System .Type (In Accordance With Table Va): �6l
TH1S SYSTE�fI H�,S �EEA! INST�.LL�D IP! COMPLIAMC� WtTH APPLlCABLE . iVORTH
C'�4ROLINA GE�IER�►L STATUTES, �RiJLES FOR SEVIIAGE TREATMENT AND DISPOSAL,
AI�D - Al:L COND[Ti�iUS OF � THE lMPROVEMENT PERMIT AND COiVSTRUCTION
AllTHOR(ZAT10N. - -
.. •
. . . �' ��r� �
,4 orized State Agent Date
lnstalled. By: ��� l'�'` S Date: � � � �`-� � .
3� Y s�� �j �PS
,�� 1�,�, � �; �PS
E z �=7oc+/
YesS�t��'.
P����-��
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W e �o /z �
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PCHQ,
,�
1Z^��°�
f�t5 t�vJ
y
S1Y� 1 �f 2 '
p ����� T��� $��t������� �u"'����.��� ���� �� - �
Tax Map � ,a ( Parc�! # 02 �S Systerri Type (T bie Va)
Ow�erlApp�icant � � Subdivision M �s �'.
Address/Loca�ion SeclPhase Lot # �
State�ID/date � L
CapaciiV__ _ ,�ozlo .
Tee and Filter -
Baffle
Sealant
Riser (ifi appiicabie)
�'ank Ou�et Seaf
Permanerrt iVlarker
Purno T�nk
/Sealant
Riser
Chec�C Valve/Gate Vaive
and autlible
� Rate c�m) . .
A roved Pum fViode!
Blocic Ut�der Pum .
Pum Removal �Ro elCt�a
. •Dis�abu#ion:Sy��i
� Serial Distribution
Pressure I�an oi
Law Pressure Pi e
r. Pi e I�ateriai and G
, �-,--_- ..
.�
Trenct� Width� � � ft.
� Trench De th "?o in.
Trencii Len � ft.
Trer�ci� Grade �
Trench S acin
Rocic De th and Quai'
Dams/Steodown� etc.
Pressure
Hole Spa
Steeve
�equi�ed� Se#bacS�
From� Welis
From Prooertv lines
� Waters
Water Suppiies
�i Cuts (>2 ft)
Lines
; �Traffic �
EasementslRighf of
�tee'
Easements Recorde
Comea�ents
, ✓�
�
��
s
pc:�d rev. 3/13/01
� Oj
Anatic�,�{C�R Datoe: - � Z�� ��j ieX iUdao ��
Amount :�aid: �p�� StfP ei,wiQS)C�5b2D �}
`� Q
Recaita'_r'�: Z�I3�Q � '�'�" Aarc.l �:
,' �-��r��y � �.21���J' �� .
. �' � � �A � ��
7 .��.�.�-�axc-a��sa9cxc�a..e�xu.�.�IL �3Lo��.I1.�L-]Lm
�Pf�l.1CATt�td FOR SEi2VIC�5
•1} P�rr�,i4 rea}uested �y: {awn�rlagenUprospectfve owner): 1�� � 'e
Hon�Er l�hons: :� �-- Address: 35'� 1i
Busi�-�e:�s Phone: �"" � e� o S
:) Naur�e anc� addr�ss �a� cunrent owmer. �n � '
�he �r�rm
:s) �rc�F�eriy Desar�ryii�oc�: Lot size: 1 l�re- Township: e ��) ubdivision:Af i�o5�u� ll�.- Lot ��
Dir�::�:tions to the propertj+ (Incfuding road names and numbers): �UIy .�g �o c��di�pro,�,
�, ,'hi�r°,�S .;�il,�%r�Ui.SJflri n�n �iGihT�
�t) Pra: �as�d Use are ��ruc'ture Description: answer ach of the following questions:
a} F�rc►posed � Existing , Type of Structure: ��� lc��iii�i�l4 � Width: Depth:
b) t��umber of Bedrvoms: ,� Number of occupants or people to be served:
c) EtGsemsnti Ye� : No Wili there be piumbing in the basement?
d) t;;:jrbage Disposal: Yes �.No �
;i) Vil�fic�r•5uppfy '�ype: Private �(new ,; or existing�, Public___, Community=, Spring _
Are any weNs on adjoining property? Yes_„_, No _ if yes, please indicate approximate location on ihe
`site ptan.
E�) Oc��_; ;�our �rapetr�y cantaln previously it9en#ified jur6sdic$ional wetlands? Yes_ iVo r/�
f'L�A�-i: �JO'i� THE �+OLLt�VU1NG:
9{h PLe'�T 0� T�-!� PRl'7P�R'�'Y �R SITE i'lJ�AI illi�US^( gE SU�MiiTTE'D WfTH THiS �1PPL8CA'd'lON.
➢"syftOP�i't'i�t' L1PiES,4WD COR�VE3�S lU'IUST BIE CLEa0.RLY MARKED. �
�"'�E PROPC�SE� LUCATiOl� �F �L�. STRUCTUREB flAUST BE STA6CED OR FL4GG��.
A"`¢iE S!'iE.9�tUS7 BE 3�EAi]ILY ACCESSIBL� �OR AN EV�ILUAT101d �`l T4�iE liEAL7F1 DEP�RTM�IVT
:3l AFF.
! hereb}.� rriake appli+cation to the Person County Health Department for a site evaluation for the on-s€te sewage disposal
�ystem �`c�r the above-described property. I agree that the co�tenis of this application are true and r2present the ma;cimum
fiaciiiiie��. ta be pEaced ari the praperty: I understand if the site is altered ar the intended use changes, the perm�i shall
t�ecam�:::�vaiid. f �'
�> r
cr
y'r /� OS"
Date
PCNo, ��. �s�x7�o2
���.�� ���.� ���T
-, � � �-�°��
IE���-�� ����,.]! ��.�.Il�.
WE�L PE1tN�T�
b'�ASE S�E A'I'��i�D �� F�It �� SI'� �'YOU'T
27� �
'�ax 1l�Iap #: _��"�_ �.'azce� # Township
_
H�Plncan� 1 0 �v � ��„ � -�-+ . .
.:� �� r ��-,, •�. =».�� .
�:.�n,,.�y�r � S1 ii i ��.i' lL� i�L.. i�'
'I'�e of W�.te� Szn��le: X Individual Communitp Public
�esauir�ffieaats- '
Site Appfoved bp
Grouting App�ved bp � �� '� � ° �P
Well Log ✓
�Iell T SS ,2 �, 07
Air Vent �
Hose B� �
Concrete Slab
�e�li %)ai�ler: ��G� K S
., i►�i �: ,. � i
:I ' � � .r � • - r ;.; .,,. ���� -_ •- -
�Ce �1�2�1C� .Sl� ��C�1�
Wells must be 10 feet from property lines.
WeIls snust be 100 feet from septic systems.
Wells mus� be at least 25 feet from aap biulding fouadation.
Other conditions•
PCi�, rev. 09/07/Ol
Z�s
���. S f I�I�I�..� ��T
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7I-:.�ca^vns�ans-xa�eaa�ml� ��.mIl�Ella
Tax Map: ' Q - arcel #: _
�ZZD
Owner: O �
ate:
3/S
Gos ,z.y�
� ��� �
��� ���
Line Tap Tap (Sch) Tap Flow Line Length Flow / foot
# Diameter(in) ( m) : (ft)
1 �/� /DD p 1
2 � a . eoo .
3 ►/� v . o0
4
5
6 �,�"" /''
7 .
8 PM
9
10
Od ft of line x,65 g. per 100 ft = = 100 =,{�� gal
75% x LQ�ga1= _1'� gal per dose Z/ 3 gal per minute (gpm) = Flow Rate
Friction Head
Loss: 0. 90 ft per 100 ft of sup ly line x.� ��D ft of supply line � 100 = Zo • 7 ft
D, ft x 1.2 =��:��t of friction head
Manifold Size: �" Force Main Size: z " PVC
Total Dynamic Head =�ft of Elevafion head + y ft of Pressure head +��ft of
Friction Head = �TDH � � �_�y����
.�-
Pump Requirem nt• 2/•3 GPM @ 37 ft of Head
Drawdown: ��al per dose = 21 gal per inch =�_ inch drawdown per dose
��� r:. �� � � ��:���
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2" min
Schednle 40
E�
4m�a
t�s.th�
]a1/ma�
s
Size
3"
u%ld Size / # Taps
Max No. Taps off one side
lace b I/: for ta in both si
ta s 3/." ta s 1" t�
4 Z
g g 3
40+ � 21 ► 1z �
" Florv er Ta
Size �Lfaterial Flvzv GP�'�i
�/ " Sched 80 5.5
�, " Scherl s0 7.1
3/, " Sc1:ed 80 10,1
=, " Sched 40 11..i
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tao�}+ratdoS .9 ' iF'�°� I°�FW°G� , .
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�ITE SKETCH • '
N�ine � . . ��
. ��✓�' G�f� ' ` Tax,Map #�?� Parcel # Z �� Z70 ,
Su1�div�i�iv ;:.. .; //�; Section/Lot# .Z��'
. �
A.tit�ibxiz d S te Agent , ,� ate .
S�►ste��: co��:pdtt�rtts �epsresent approxinaate contauss only. The cont�rcc�`or n:ust, flag the systens prior to beginning tlte installa�ion to insu�e t�idt
prn,��ea•g»ctde is 1�3affztained. , '
�,
\
�6
���%100�
Cot�trol
Combr
SuppN�
� Easa.
. �r�ton
Contr°1
Comer
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IOAc�,. '�-���,
� `T'n►a�..
23
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C��q-ZSS� 2�
3)
4)
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; �L�°.�-. � �� 6)
� ` .
\
15' Supp�Y
llne Ea8°•
�
S;
C
� -c Arn�ld _,
.:�.
'�•,�►aV��i F�1''�i �L ✓
E��EMEaT
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L�T 2•�
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_ __ _ __ _ _ 7l� ZZb,
Notes
All supply lines must be installed at the same time within the supply line
easement.
All supply lines must be pressure tested before lines are covered.
Prior to installation, supply line and drain field easements must clearly
marked. Contact Surveyor if in doubt.
Drain field layout is approximate. �
Pump requirement (TDH) is estimated. ;�
Any questions contact Person County Health Dept. (597-1790).
!� �5 I ��,y
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i i ' ��4av�f.t�i'T'
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r,�
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-�ta,o �r� . �'�r,- �����-r-� �,�,
3 V 1�f� �. I!� G� '
0
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r
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v! ...��Q:n7�� in /v lt 1�, .
LOT 24 EASEMENT AREA '
�/s�t-wt' L.ayo t� T"
PCHD, t�v. 09%i2/.01
�,`-�`�.5� _ ' ��e�:� �.��
`�'� � _ ._ cC � ZLT 1� �I" �`
�arnwa�-aass .�rirn�yn.��.A:• '��a�':n'i.II�ga
�wner: ,�
�ocatiott: •
iubdivision:
�°'�3�
uat� uu � �..�� -
t�� a� --(�--��r ` � �` � �
D� � �'� ��d�
Grout Log ,
Ta�c Map � Parcel # �,�
Lot #
� Well Construction
�isiance From nearest Property Line (Minimum' 10 f� L�
�istance from Septic System (Minimum 60 f t) ..
Total Depth�� --- ft Yield: �� �PM Static Water Level: �� __ ft
Water Beanng Zanes: Depth 9' U- f� ft ft ft
Casing:
Depth: t�rom `�_ to �'�_ ft, Diameter: _�_ in
T e• Galvanized Steel
i
�� �(n��
1-13�1�1
1�%�{er �.�11 ZaYd S
yp . �
W�;g�t; �, T}uclmess: ��_ Height above Ground: in
Drive Shoe: �es No Any problems encountered while setting casing7 _�Yes �o
if "yes" give reason: . _
Grout:
Neat: Sand/Cement t� Concrete Gravel/Cement
Annular Space Width .3 inches Wat�rr in Annular Space Yes ^�. No
Method of Grout: Pumped Pressure �Poured Degth �� to � Ft.
Materials Used:
No. Bags Portland cement _ Weight of 1 Bag ��Paunds
If mixture (sa�nd�,� vel, cuttings) — Ratio �. to.���
ID plates: (�es � No 4 x 4 slab '�Yes � No
Liner:
Depth: Date InstaIled: Grout: Insttilled by: _
From � To
DriUing Log
Formation
Location Drawing _
1 hereby certify that the above information is correct and that this weli was construcied in accardance with reguiarions set forth
by the Pcrson County Health Depar�gnt. � j ,
Slgnature of Contractor
ID # � DAte �%��, 0 -b
Pump Installment
Pump Installation Contractor: State Rogistration Number:
Pump Depth: ft Static Water Level: ft
Pump Make & Mod�l: _ _ Pump Size and Rating: _ hp gpIn
I hereby certify that this pump was installed and the well head completed according tu the Person County We13 Rules in effact
on this date and that a copy of this record has been grovided to the well owner.
c���Y..�, Tncts�liPr Cianah�re Date: PCHD rev Ol/2ilU4
���,s f I���.� ��
- �- � � ����
-�+ ua�vnaramna�a��rn�an� �L��.Il�7�a
WELL PERMI'T
(New_ Repair�)
Tax Map: Parcel: 5 �
Subdivision: � �Q,
Applicant's Name: J p i I�y�
Mailing Address: �� ea� �a t
F�o X �D�fO I�/ �
Phone Numbers:
Location of
Lot:
s�n � l% ot� �i�ar
Permit Conditions:
1.) See attached site plan for proposed tivell location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee otable water supply
Other Conditions/Comments: __ Qi� r,�ni �ci �rr � i'v1 f
i
1- i3-��f
�Tew Well:
EHS/Date
Certificate of Completion ,,.��
Lldi.iner:
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
� ,
Well Driller: ��,Q v 11'
Pump Installer: �
Approved by: —
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
EHS/Date
�"i�" �
,.S `( ' _ -��
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: -
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-78QB
11/26/13
PERSON COUNTY HEALTH DEPARTMENT
35�A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant �p /yt � f/n� n/�/i� i
Address Lpf' 2. y ��i,� u71' County p1/'So ti
�,o s-G v � lii_
Collected By � �C� C//Y
Date CollectedTZ�d� Time Collected %/ ' b O'
Source: �ell ❑ Spring ❑ Other
Location: ❑ House Tap ell Tap ' ❑ Other
pNo Charge harge
�����**��*�*�������*��*����**��������,��*�**���*��*��*�***��*��****�:��:��*���***
*:�����*������������*��*��*��*�**������*��**���*�**��,���:�*�***�*����**:��**���**
Total Coliform
FecaUE. Coli
Results
Present Absent
❑ C�
❑ LY
Reported By C�����' `���� I�'1T
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