A29 55BD�1 Gl hl�� }��'�rvti r c�l nl NoT /I �' Loc�17�D
`� �erson County Health Department
Sewage System Improvements Permit
Date: ' Permit Void ter 5 Years Pennit #
Owner: SR#
Location/Directions:
Subdivision Name: - Lot # '
Lot Size: Type of Dwelling:
Water Supply: Private: Pablic: Community:
Bedrooms: Garbage Disposal
Basement Basement F'vctures
INFORMATION CERTIFIED BY
S��an: ownu or representative
REPAIIt: REEVALUATION:
Size of Septic Tank: gallons Size of Pump Tank:
Nitrification Line: �
Depth of Stone: 12 inches
Max Depth of Trenches:
Alternative System: Conv. Pump LPP Pump
Remarks:
-------------------------
Date Well Approved: Well should be 100 ft� from any sewer system
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
CERTIHiCATE OF COMPLETION ,.,3
Contractor. �
------------------------- �
b
Sewage System location. installaaon, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a�wblic health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County
Health Department before any portion of the installation is covered and put into use. If �
the site plans or intended use change this pernut is subject w revocation. --�
(G.S.130 A-335F) �
Location of sewage disposal sewage system sketched on back. �
(OVER) �
� NOZ�: Make sketch oi installation showing , lot size and shape, location ot house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
�;�at later date. Note location of water supplies on adjacent lots.
(1)
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(2)
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rson County Health Department
DATE
OWNER
ADDRE
DRILL
WELL CONSTRUCTION
Distance from Nearest Property Line Distaace from Source of
Pollution d
Total Depth: Ft. Yield:�.�_GPM Static Water Level Ft.
Water Hearing Zones: Depth `2�Ft�f^j, Ft. Ft. Ft.
Casing: Depth: From�to��Ft. Diameterz % Inches
TYPE: Steel Galvanized Steel `�
Zf Steel does owner approve: Yes No
Weight:�Thickness:��Height Above Ground: Inches
Drive Shoe: Yes �u. No
Were Problems Encoun ered in Setting the Casing? Yes No_
If 'yes' give� rjea��n:
Grout: Type: Neat l/ Sand/Cement Concrete
Annular Space Width � Inches
Water in Annular Space: Yes No �
Hethod: Pumped Pzessur�-- Poured t---�
Depth: From � to o1V Ft.
Haterials Usedx No. Bags Portland Cement�Weiqht of
1 ba lbs.
9 /
if mixtur (sand, gravel, cuttings) - Ratio:_�to
ZD Plates: Yes ✓ No
4 x 4 slab Yes V No
DRILLZNG'LOG
De th
From To Formation,De criotion
� �
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I HEREBY CERTZFY THAT THE ABOVE INFORMATZON IS CORRECT AND THAT THIS
WELL WAS CONSTRUCTED IN ACCORDANCE W7TH REGULATIONS SET £ORTH BY THE
PERSON COUNTY BOARD UF HEALTH. PERMIT VOID AFTER THREE YEARS.
S' ur of Co ractor Date
i. , �/ )
Sani arian' nature Da e s uecy
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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AFPt3CATi0IV �aR S�VIC��• .
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CaiwSTi�flJCT Si-!l�LL BE�aRAE IAIi/�lL]D.
1) �emrad� rec�uested by; (Ownerlage�a�lpr�s�esiiv� own�ej: �� O��ib ll
Home Pt�one: _� —(o(� 3 Address: . ; �
Business Pi�one: �
2) �larra� aead address o� curren� owca�a:
3) Praq��r�+j Descriptioea: Lnt size: Township: Subdivision: L�t �
Dire�tions to the property (Incfuding raad �nes� d n bers):
� , l� q S o � ) ���.- -
,
. �',
�} F�ro�os�d Use and Strsac3u� D� scri�tion; answer eacf� of the following questions: �l �� � I � �2
a) Propos� _, E:isting ,/ Type af Structtir�:_�nJ .�r1; t,r-t �-'S�,r,rr �JVldth: Denti-�:
b) Number of Bedrooms: Number of oc��pants or people to 6e ser.ved:
c) Basemen� Yes .(Vo �i! t�e plumbing in the basament?.
d) �arbage Oisposal: Yes No� , �
�) V1la��r Supply T�e: Private _(new _ or e:.istin9�� ublic_,✓ C�mmuniiy_, Spring —
Are any vvells on adjoining proQarty? Yes_✓f�lo _ If yes, please indicate appr�:ima#� Iccaticn cn the
. 's�te pian_ : .
S) �oes yoane� propeaiy cz�n#aira pa�va+oeas�y isd��ziin�s� ju�asdirKima�a! �nre�iaa�aais? `(es,� i+�a� ti�'f
P�:�,S� r�DTE Tt-iE Ft�Li.01fVING: ' •
�� Pl�T 0� T1-dE P4�����Y OR SBT� ��AS I4liUST BE �U�M9'3"�Ei3 WITH T�iIS �'��..]�A �3�1V.
��ROP�ZTI L1NE� �AMD CflRAI�S MUST $E CL�.�"RLY 14�,RKEil..
y T�-IE �'ROPOSF� l.DCAT7Oid O� �LL ST�UC'Tll�S NiUST BE ST��� OR ��,G�E�.
y i'r�E Sli� t�IUST 8E R�D1L'f 'AC��BSi�l..� ��9� }�1� �ill��.11A7740�8 8� T�iE H�LT,t3 i�EaARTitfiE:dT
STAF�. �
I hereby m�lcz apQiic�tic� tfl the Persan Caunty Health .Departmer►t Tar a sifi.� evaluotion �or Ehe on-�iie s�tivage dispos�l
sys=em ;er the abov�-desc:ibed proparh�. I agre� thax the c�ntents or ti�is appiicaiibn are true �:nd r�present tY�e ma.imum
�ac:liiles ro be placrd on the p �tp''I understand iT ihe siie is altere� er ti�e intende-d u�a cnang�s, the permn sn�ll
be�a , i aiiif.
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T�x Map � � ` Pa�rcel � � —
Su�bd'ivis�ioia
Fh�se Sect+ion Lot #
Improvement Peranit Zo �,..rs
Permit Valid for �ive Years No Expiration
Type of Faciliiy: r P.Cc'�����-i-e� ��-- New Addition � Water Supply � b i � e,
# of Occupants # of Bedrooms Projected Daily Flow _�� ' g.p.d.
Proposed Wastewater System: [�s,,,l ��� �.�.,. o,� �.e, w�: � M � Type: _"i i'= }�
Proposed Repair: ��,` �/s_ ��k a �.e _ p w ��-�.�� Type: 'iTe �
Pernut Conditions:
0
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#�7-i796 ,-
Owner or Legal Representative Signa e: /� Date:
Authorized State Agent: Date: � O
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 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 Sewa�e 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 Const�uct Wastewater System (Required for Building Perrnit)
* See site plan and additional attachments (_�.
Proposed Wastewater System: C�o�✓✓��,/,l��� ��� D�.
Co
New Repair� Expansion
Type of Facility: � ���_�(�.��i.,r,r0�,��,� ��-c�
Type � Wastewater Flow 3� g.p.d.
C.,;1 T T A i2 • _-7_'� a n r� / ft 7
M4 CorJ�f�r is'T"`�
Wasiewater System Requirements ��-,c -rA.►� � r-
� �r'zuG-ru�uy
�c� :1i� .
Tank Size: Septic Tank: /O�1Q gal Pump Tank: /�C% gal Grease Trap: 1GiO D gal
Drainfield: Total Area: /�d sq ft Total Length � D ft Mazimum Trench Depth %� in
Trench Width 3 ft Minimum Soil Cover: ro in Minimum Trench Separation: � ft
Distribution: Distribution Box
Specifications:
Serial Distribution _ZC Pressnre Manifold
. . - .
Authorized State Agent: Date:
Pernut Expiration Date:
The ty�e of system permitted is � Conventional Accepted Alternative. I accept the specifications of the
pernut.
Owner/Legal Representative: Date:
PCHD rev. 11/10/OS
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15' WASTEWATER
PUMP LINE
EASEMENT
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II�:.aa�na �nnsxa�an�.m� �r�.m��Ila Owner: �D��f I ('� GiPLU��'ti1 "�'�`'` ���.v�
Tax Map: Parcel #: 05� S�_ Date: S �
Line Tap Tap (Sch) Tap Flow Line Length Flow / foot
# Diameter(in) : ( m) :� (ft)
1 �/z ? � Iv�' - O�
2 '/y d 7•� .o�
3 �/y �0 7•! �Olv
4 '/v �D • o
5
6
7
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9 Z�• 5?St� �-rt•
10 �^�
00 ft of line x,65 gal. per 100 ft = =100 = 3�Sga1
75% x 3��a1= Z o gal per dose �• gal per minute (gpm) = Flow Rate
Friction Hea�l
Loss: -�����7� ft per 100 ft of s pply line x��_ ft of supply line ; 100 =�- .�� ft
��T"� ft x 1.2 =� ft of friction head � �
Manifold Size: .3 " Force Main Size: �- " PVC
Total Dynamic Head = I o ft of Elevation head + Z ft of Pressure head +�ft of
Friction Head = I� TDH � �.�.,,�,�,�.}..��
Pump Requireme t: �� GPM @ 1� � ft of Head
Drawdown: Z D al per dose = 21 gal per inch =� inch drawdown per dose
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Size / # Taps
No. Taps off one
y 1/= for tapping �
Z� � 'h" ta s 3/." ta s 1" t�
Schednle 40 �+. .Y .,.Y,.w.,.+. •+�+ ; Z�+ 4 Z
p � . . . . . . . 3�� g S 3
y1.ti�1r1•'M1�'1•1��.W1•y MM r
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9m�mor �� � (�n qp} 21 1:
. " Flotiv er Ta
Size Maierial Flow GPll-1
;%" Sched 80 5.5
;; " Sched 40 7• 1
3/, " Sclied 80 10,.1
3� �� Scl��d 40 12.5
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
� �
Dat of In pection
3�fov ��
2z � o � �'b �Q Ss►3
System Installation Date Type Tax Map Parcel #
����
Property Address
G�v �C P?�
Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and
comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks 7
Tank risers accessible, free of
infiitration and surface water diverted ?
Septic tank n,.eds p mping ?
�nches of solids: '�
Septic tank filter cleaned ?
YES / NO REMARKS
� � '� �� �`� t���e r n �t�� ��� =�a-t .
� }� p/k� f S �-f�' !/1��� o��f"
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EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids 7 «
Inches of solids(pump/dose tan�C):�_
Elapsed time readings ? /t'
Counter readings ?
Drawdown rate:
►: .
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DISPOSAL FIELD:
Evidence of effluent surfacing ? �
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? �
Diversions/swales properly maintained ?
Vegetative cover maintained 7 �
Protected from tr�c/unauthorized uses ? ❑
Distribution devices in good condition ?❑
Field free of settled or low areas ? �
/
/
/
/
/
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ON� �.q���'�e�� ���4 �'� �� ��c�r,
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r�v�-�- Ya�►-a� � c� �es ,
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PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? ❑ � � � n ����� �r`�.Q,�
Pressure head properly adjusted ? ❑/ fJ l�
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
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Apr 14 06 07,38a Keith L. Barnette 336-598-9275
Narth Carotina
Departrnent of E�vironment, fiealth� & Nahual Resources
' Divi.sion of Environmen�I blanagement
, Groundwater Section
' P.p. Box 29578 - Ralei�h, N.C. 27626-0578 '
CONTRACTOR D; rr�a„�`� �" FJ..ti u� REG NO �,3 %�j
:"-;----
1. WELL LOCATIoN; (Show a sketch of the location on �back of form.)
Nearert Town: _�A�: � n Q c� County �� l2 S oicJ �
�- 9 � �' a �-f-/� He s ��f� ��.
(Road, Communiiy,. Subdivisio�. I,at No.) � guadrangle No -
2.OWNER�oS2Ui//2
3. ADDRES�:
4. TOPOGRfs.PHY : draw, slope, hilltop, vall , IIat '
5. USE OF y4'ELL: e� ._ DATE: _' i� /2 -�Q
6. TOrI'AL DEFTH: �DIAIYIETER '�
7. CASING REMOVED;
. ee
d N`�
8. SEfiLiNG iYiATERIAL: �
PTeat cement
ba�s of cement
g.:1s. of w�ter I
the--
"I`�rpe material
Amount
. . �� • - ,�
S ce en • q
bags of cement �
yds. of sand /
gals. of water ,Z,S
u
9. E3�LAIN NInTEiOD E�VIPLACEitiiENT OF MATERI.4L,. �
`}- r.t ) r�h �2; m L i N�_
WELL DIAGRA11rS: Dra�r a deiailed,sketch oi
the well siiowing tofal depfh. depjr.h and dia-
meter of screens rPma;,,;�� �{�� W�, gY.-.G�ei
inter✓aI, infervals of casing perforatior�s, and
depths and types of fill materials used.
I eo he=e�y ce:-�ify that this ti�e1 abandon:.--1eat record i� true and e.�ct.
�iY�zture oi Contractor or A�ent �� �', ����
` ,..`_Date � � E�
14'ELL LOC��IOv; Drar,r a locarion sketch on the reve:se of this sheet, showzng the direc_ '
tfon and disiance of the �e11 to at least two (2) nearby refe=ence points
such as roads, inte:sections and s;reazns. Identifv roads w-ith State Iiigh
w-ay road id�ztification numbe: s, .
Submit o:ig�n�1 to the Division of Enviroririe:�ial M�na�e:ne:�t. one copy to the Dr:lle:,
ar_d one copy to ttre o�vner.
GtiV-3Q Revi�e� 3/9E
o c�Na
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3� ar� s � no�
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