Loading...
A29 255��� s� ���.��� , '. , � � � ���� 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 � � � ���� �� ���� �� 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����-�� �� ��,,�,�� e I�P �1, � �.��,�.�,��- � �o�,�s 1 h� W e �o /z � � c� ��- � .�,o �-a�o� � � �' s�� � 2 � 1 � �e , � � pT 5 i — r �a � 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 �-----' �= � � ���°� 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:. �� � � ��:��� �� � - - � �� — ��i�����t� �_ . . , � _ . . . • i�i ' � - ,. , 1 I �[t�)1�0000 �) �I 1�1 1�1 �����iiiiiiiiiiiiiiiiiiiiiiiiii -.... .. . „ . ��ii���ii���i���i��i��������i�� � � � � �. ; � - . a ; : ; v. 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 � ' 1.• �i. . ' : ` ' : x � • . • � .t • �.:•� , • . . . .:�•',��,�it•11fi.i ' . • ' . • • +• • . . • . . , � •�\�:('' . ' • • . A�. 'i • . • • ' • . . . . , . . " . •Ai��. F- %�'a• ��..." .. . _ . , . . 1 . • . • • , ^ � .J'.LJtiL Y rL �JIi1.11�7.1'il.V i l Y M Q 0� • � , � i� � �• • i � � • � � • ' � : i w, f •� � � .� � �A � � . • %� ` . �' �• � l . . �.•i •• �'t . . � . .�� . �IH . .dOt���R � S� 1•; � . • � • . fi�.L �i�� i�d : ^+ . � y i �R�G.7 r� , • . . � 5.:� . - . . , � 1 — .• � . . � � .q��������Z '�' . • . ,a ,; ��x�i, i1OLi d 1 ' i '+ '�q°��a�g-� � �N y�p�Q � : ' • .,,', � , . �� :: ri*°Li �[�`tmQ+rA,� �' t=., ' , ' ' • ' RO �'-iusZ�B ` '' y� � . •- (��s.� � � ' ; • t.es�a��mnt� . .. ; ;� �� i�Li �edog� '�laA . '. e�d alld06�5 rS ' °�H �°�J •• � d+�d �18d Oy x�S ��Y �a�s��m►a ,�.I . . . a�s� :� ��� ��.�a�s���� � ��Ya'I�od ' � � �dd r"E,� �i°H�i�S�T: �IFM1��T �d0 . • � . . � . fi�l414���p � � ' P� � ' ' .. ' • - • �.:• . . , . � :. : - • �.- � r , . •� . � � . ��a ;� ��:. • v � � • �;� ; �•� •�� . ' 1�Ao1��d . , � ' : • ; • : .. '•� � ' • ' �•�a� 9 j • j �trao� tr��ay • . , av �. �'�'� �: r • ��ri ` .' � � '' �'' '' " • � �RA � 'P'�1°� � . tao�}+ratdoS .9 ' iF'�°� I°�FW°G� , . • . . �. .� � ��r�e �i�d�S.Gi ss�11�.P"{Sp.L4�RS . • _ . ��g ��e�o� �aJ �iZ�q R� � ad 4��*�.L ��d.i X.b fi°HF°9�Q � , 1O0D'd i°�'"J �[�FS �t 1�P4�H ' 41� �s2 -� �' 3��°�1 .�-� ��.�� � �� ss � . . �� � ]� � 1 � �^�� �.� `�•• = � J � `�..J' � � � � � � � I����.�-.�������.Il 1E��.�..Il�I��. �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 � ,� �P� � ���-•r,�, '. .. _ IOAc�,. '�-���, � `T'n►a�.. 23 . 1) C��q-ZSS� 2� 3) 4) , „�g,. ,��.:�� .. s) � ; �L�°.�-. � �� 6) � ` . \ 15' Supp�Y llne Ea8°• � S; C � -c Arn�ld _, .:�. '�•,�►aV��i F�1''�i �L ✓ E��EMEaT ��, -�2 L�T 2•� (� - _ __ _ __ _ _ 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 !' 1�� r1$ i i ' ��4av�f.t�i'T' � ' 1�`�S • � ,���F ' . �''c ; ; / '�'�'F�< I O • . �l `� �pT � ;� .,� .�,� R 's� �� �� *i. �� F�' s�9e s �s� -... -- . �..y�, s,�, . "'-. -.,. �� � � �/,���0.` ` �`��.,;, � •` .. ` ,. � "','v C7T-''-"/ . ���2���. . �"` F e ~ I.-t �( r. ~ ��`f +�� r,� � N� 4.�t � r=� c�� . ! -�ta,o �r� . �'�r,- �����-r-� �,�, 3 V 1�f� �. I!� G� ' 0 � ,� _ so� r � ti �p� . � � 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 bactreport . - �"�'���. �,� t����' �r�.���e �� -L- �Sa ' ,��v� v�/,���>�� '�" �ti �,�t� � ��/`�T % �i�QQ�"s,.G�'�.�P �+��� f � � •�I V � "'{�j_�7T' /�+:O�iP i�Fi ���'�e� ��i�"' ��vi'J`�i�,yr�� v � � ,��,!����� �'f�t/� � _ Z�.�,� Sec��- `� B. � ' ;.�5