A31 115� Application Date: � ' � � " � � .`��+�� ���� �� Tax Map: �
Amount Paid: 3 00 ,00 _�..,�- Parcel#: 11 Sr
Receipt#: �i I �.2f� _SYred,•�-. ������
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Application for Services
Services Reauested
Improvement P (Site Evaluation)
$200.00 300.00 f> 600 �pd)
❑ Mo6ile Home Rt�ement or Building Addition
$150.00 (if site visit required)
❑ We11 Permit (New/Replacement/Repair)
$3 00.00/$200.00/$75.00
� Construetion Authorization
(Fee is dependent on the type of system permitted)
� Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information:
Name: �iPP� �RF-�L�
Address: _ _g/ g �l'Cll�(l1(/�l!'r ��R TiPL .
6 C
2) Name and address of curr nt owner (if different than applicant):
Name: 5��
Address:
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property:
C9GL ?�tiy
Phone (home): `� �9— ��/—%33 `� `�
(worWcell): 9/9— a3 — �/S�8
Phone:
Lot #:
❑ yes L��7� Does the site contain any jurisdictional wetlands?
❑ yes [� no Does the site contain any existing wastewater systemsT
❑yes C�d'no Is any wastewater going to be generated on the site other than domestic sewage?
Q"yes ❑ rle' Is the site subject to approval by any other public agency?
❑ yes Q no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4) Proposed Use and Type of Structure:
❑Kesidential
❑ New Single Family Residence Maximum number of bedrooms:
❑ Expansion of Existing System If expansion: Current mm�ber of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plwnbing fixtures? ❑ yes ❑ no
L�fNon-Residential
Type of business: ��c��it� S/Lf Total Square footage of Buildin :����(g
Maximum number of empl yees: _ Maximum number of seats: �
5) Water Supply: ❑ New well I.J �xisting Well O Community Well ❑ Public Water ❑ Spring
,Are there any existing wells, springs, or existing waterlines on this property? ❑ yes � no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
C�}� onventional ❑ Accapted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
1 cer�� that the information pravided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subseqarently altered, or the intended use changes, all permits a�id approvals shall be ir:valid.
(Owner/ I�gal Representative*)
* Supporting documentation required.
/ /S Zot3
Date
Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map: � Parcel: ��S
Subdivision
Phase/Section/Lot #
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Improvement Permit
Permit Valid for: Five Year � �c�n-expiring
Type of Facility: � New Addition
Number of Bedrooms / Occu nts / Employees 3/ Seats: �
Proposed Wastewater stem:
Proposed Repair: �U✓� �o�t
Authorized State Agent:
(X) Owner or Legal Re
Water Supply: �
Projected Daily Flow:? .�Sgallons/day
Type�
Type: �
- C. i�• N,� t( lae
Date:
Date:
The issuance of this permit by the Health Uepartment does not guarantee the issuance of other requir�d permits. It is the responsibility of
tl�e appiicant/property oamer to insure 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 is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the PTorth Carolina °Laws
mrd Rules for Sewage Treatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable. __ _
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: �(,�,�� �i�vt�iDK�� (*)Type �6 Design Flow �3 SDgal./day
New Repai Expans n L�� Soil LTAR: • 3� gal./day/ft2
Type of Facility: �urAN S�-2 �" A�—�-'�T' Basement: _ Yes � No
(*) System Types IIIb, Illbg, IV, and V, require periodlc system inspections by the Person Counry Health Department.
Wastewater System Requirements
Tank Size: Septic Tar�k ���� gal. "
Drainfield: Total Area `C 7fl sq. ft.
Trench Width � ft.
Distribution: Distribution Box / erial l
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Snecifications: �$e, � � . r
Pump Tank � � � � gal.
Total Length�� �� ft.
Min.Soil Cover,� in.
Grease Trap ��� � gal.
Max. Trench Depth � � in.
Min.Trench Separation � ft.
/ Pressure Manifold �
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A�tharized State Agent: �; Issue Date:
Permit Expiration Date:
The system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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�i S1TE PLAN
Name �• ! l�i/� X�• Tag Ma �# • J� Parcel #�� S
, Subdivisioa P �
Section/Lot#
� Authosized�StateAgeat Date � '
S�� �+� P petgradeisaum �te con�brns aalp. The conuaact�vrrJttstBag the systempdotm b:.�,piaa;ag rfte iastsllation m
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http://gis.personcounty.net/connectgis v6/DownloadFile.ashx?i= ags_map6a4883c111974... 2/13/2013
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David Poindexter
Flat River Cafe
Tax Map A31 Parcel# 115
PERMIT CONDITIONS
Information for the Owner:
nsuring a healthy environment
1. Grass must be established over the drainfield area and cut when needed.
2. Precautions shall be made to reduce the amount of wastewater flow into the septic
3.
4.
5.
6.
7.
8.
system.
Low flow fixtures should be installed when/where applicable.
Single service items should be used in the restaurant when/where applicable.
Cleaning andlor washdown procedural changes may be needed to reduce
wastewater flow.
Any other means necessary to reduce wastewater flow into system.
Owner may also want to install a flow meter on the well and start documenting
monthly water usage to potentially be granted a flow reduction for the septic
system.
The Construction Authorization for this system will be withheld until proper
documentation is submitted indicating property ownership (i.e. deed, plat).
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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David Poindexter
Flat River Cafe (Repair)
Tax Map A31 Parcel# 115
PERMIT CONDITIONS
Information for the Installer:
nsuring a healthy environment
1. Pre-Installation meeting mandatory.
2. Contractor must flag lines on contour after clearing/removing old store and have
layout approved by health dept.(may revise manifold setups if needed)
3. When clearing drainfield area and removing old store disturb soil as little as
possible. Pond must also be drained.
4. No site work should be done under wet conditions.
5. All tanks must be accessible from grade.
6. 3in. pump line must be installed
7. Control panel box shall have event counter and elapsed time meter.
8. Zabel A-100 filter shall be installed in septic tank.
9. Mini-manifold or Mani-tee may be used but permanent iron stakes must be
installed at all corners for protection.
10. Accepted product may be used in place of gravel but no reduction in line length
will be granted.
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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I.ine Tap Tap (Scfl�) TaQ �'lo� Line Length �"lodv / f�ot
# i)aameter(vn) ( m) �:. (ft)
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75% x�_ gal = 3 4��a gal per dose 3 7 gal per minute (gpm) = I+'low I�ate
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��� � ft x 1.2 =`f•S ft of friction head
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Manifold Size: 3'� Z"� Force Main Size: 3 " PVC
�otal Dynamic �$ead ="' �S ft of Elevation head +�` ft of Pressure head +�� ft of
Friction Head = 2S TDH � 2-,�.�a.,.�'o�dS
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Pump Requirement: � GPM @�s • ft of Head
Drawdown: �gal per dose � �2''1 gal per inch =_j.,$ inch drawdown per dose
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I�ine T�p Tap (Scli) Tap �'lov� Line Length �'lodv / foot
# Diameier(iin) ( m) � : • (ft)
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75% x 5�''�. ga1= 3$� gal per aiose � � gal per minute(� m) = I�'lov� Itate
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3 � Q t� 9�-�-�$riction �ead ,
���- I.oss: 2• o ft per 100 ft of supply line x"' � 7o ft of supply. line = 100 = 3•`� ft
Sc� 3� Y ft x 1.2 = • 5� ft of friction head �.
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Manifold Size: 3 X 2 " Force Main Size: '� " PVC
Total Dynamic �$ead =^'1S' ft of Elevadon head + 2� ft of Pressure head +�` �ft of
Fricdon Head = ZS TDH
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Pump Requirement: �� GPM @ ZS • ft of Head�
Drawdown: r12 al per dose :�igal per inch =�$ inch drawdown per dose
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