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Applicant: ���1 i t, �„� I 1 �►�am.5
Location: /S 7 S�l2 (,tn i c� n G ra � c. C� u �c �
Ta�x M•a� � F�rcel # �
S�uhcliivi�5�ion
Ph����se S�cGion Lot #
L
% Improvement Permit
Permit Valid for V Five Years No Ezpiration /
Type of Facility: i � m i/ W �/ / I�► New ✓ Addition Water Supply �i,,a.�- W<<I
# of Occupants g m�,, c' # of Bedrooms �_ Projected Daily Flow �� g.p.d.
Proposed Wastewafer System: U,mo Cp� Ve./t-�i Ona ( . Type: �
Proposed Repair: t,�. rr, n=n n � vc�-�i � c. as� 1� (Lc d�.�-�� o n) Type: j���'�
Pernut Conditions:
mr�.s � �c. r
Owner or Legal Represe
Authorized State Agent:
m�n Cvn{�ur c�s Fl�yGc / b� EffS,
n
a.� 9�.
Date: � - � � ��
Date: �-1—z23
The issuance of this peimit by tt� Health Depariment in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspecrions requirements aze me� This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Lnprovement 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 Sewage 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 Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments ( V C� .
Propos Wastewater System: �umo Convcn-�i c�na � Type � Wastewater Flow �.p.d.
New � Repair Expansion Soil LTAR: � � g.p.d./ ft 2
Type of Facility: � iny Jc, Fam � I�� t71,,J �/� �'n.4. Basement Yes _ No
Wastewater 5ystem Requirements
Size: Septic Tank: l, aso gal Pump Tank: I � o'�,SOgal Grease Trap: N � i� gal U.QS���`
� � ��,�
field: Tota1 Area: �.2�ssq ft Total Length J s ft Mazimum Trench Depth Q�4 in
:h Width � ft Minimum Soil Cover: � in M' ' um Trench Separation: _I ft
ibution: Distribution Box Serial Distribution v Pressure Manifold
Specifications: 1 IaU
,�ihoul�l. be. �CiUt
Authorized State Agent:
`I�M4n�fald S cc.' t'ca.-Hon,S, le
.,Sc. Fo� �i 'n���l c.r�vcr �vcr �
" oF
c, dk�. �0 SfoPc-.
Date: S-I�t�
r�t 40�
Permit Expiratic�n Date: s- I- O g
D
The type of system pernutted is Conventional Innovative Alternative. I accept the specifications of
the permit. � � '
Owner/Legal Representative: Date: ���`� �
PCHD7/30/2002
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Il '.sJl.lL V" .LL.Li. `WJiJi.�Jilili`VJiJL.V�'�� J.L J.L`l..i����
Building Additions/ Mobile Home Replacements
Tax Map #:�L
Approval Requested for:
Parcel#: �D�
Mobile Home Replacement
� Building Addition
Applicant Name: � i � (fl
Address: a � q .` E Lo ►v o A
c.t l C- /�"l, `! ?� -
Phone #'s: 33G�- 3��-ag �S 9! g-� g7` 3 ZZ�
Permit Located: `� Yes No
Installation Date: Design flow: � (gpd)
Current Contract with Certified Operator on file (if required): �
l,
Water Supply: � Well Public or Community
Wastewater system shows no visual evidence of failure on: �'` �� � (date)
(Applicant's signature if site visit is not required) "
f �' n_/`
Comments: � � � �G ��i l
I
Addition/Replacement Approved
_ �
Environmental Health Specialist Date
11/15/OS
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CAR�i.YNA GE��AL .STATUTES, -R!lL.ES ��t� SE�IfAGE'.'FRE�I.TMEN'C AND i�tS�L._.
AND ALL [.'aNDCfIflNS : OF : Ti3� _I�PRQVE�E�IT� PE��A1T AND. •CONS�F�3UC"�10[01 �.
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IE:.aa-vnr�naaan�ean�m]L 7HL�,m.11�f� Owner: Gl i (.
Tax Map: �i31 Parcel #: I�+ � Date: 5- I-03
�nne Tap Tap (Sch) Tap �ow Line I.eng#ta �"iow /%ot
# IDiara�ete�t�) ( m) � (ft)
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535 ft of line x 65 gal per 100 ft �,� � lS 34, ��S ; 100 =3`�����al
75°lo x�v4E') ga1= �( gai pe� dose 0.1 gal per minute (gpm) _�'low l�ate
FricNon Head
I.oss: o�� � ft per 100 ft of supply line x �� ft of supply. line =100 = u��31 ft
d�3� ft x 1.2 = o�� 8g_ ft of friction head
Manifold Size: �Jati � "�'orce Main Size: o� " PVC
�otal Dynamic �ead =�i(�i ft of Elevation head +�_ft of Pressure head +a� gA ft of
Friction Head = aq.�4 TDH
Pump IZequireanent: 3�J GPM @ as � ft of Hea � Q
Drawdown: (�¢ � al per dose =�gal per inch =� inch drawdown per dose
ZSC ��So �.t �on Tu�K)
�nexxl �esign �nff'urmataon
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Size lYlruerial r'Tmv GPY!
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j, • Sched �0 1? �
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MOIVITORING REPORT
l l 18 1`l 7-�1- a`i- . u d f1�1 ►b5
Date of spection System Installation Date Type Tax Map Parcel #
aqag c�� �oa6 F o,�uu�. r�,.�.� ,�c. �7 5�1 �
Property Address
Instructions: Check yes or no for appropriate items and explain in spa;,e 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 aze to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted 7
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
�equire� pumps pres�nt & functi�nal ?
High water alarm operating properly 7
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ?
Inches of solids(pump/dose ank): L.3
Elapsed time readings ? �
Counter readings ? _
Drawdown rate: o� \ �
YES / NO
❑ � ❑
❑ � ❑
❑ � ❑
►_.
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t� ■
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DISPOSAL FIELD:
Evidence of effluezt surfacing 7 ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? �
Diversions/swales properly maintained ? ❑
�egetadve co��er rs�intzned ? Bj
Protected from traffic/unauthorized uses ? [�
Distribution uevices iii good condition ?�
Field free of settled or low areas 7 '�
/
/
/
/
/
/
/
/
►!
�
■
■
■
■
�
PRESSURE DISTt'tIBUTION SYSTEM:
Turnups/clean�uts/valves/taps intact &
accessible ? � / ❑
Pressure head properly adjusted ? / ❑
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
►_�
■
■
REMARKS
S�Prc. ��1X. t�cc�c A��.ss �i�v.
aa�v�, 6v.,�a� �iaco Ac�.ss R�s�aS;
gss..i 2.S''�►��
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qa0�,� '�RSo�� av�,-tl. S�'D �S .
t1I'iuiTiulviw Cvivil�iailTS: �I�IA�i� '�� '��� Q�h4�7p �-'�7L,=R.�i 3—S �{i�'
CL,E�-1�� `��c. S�S's►C.. ' �3�1v�.�` �F-FU_'1-���C �'1�FQ_ �1aw1��...`t + C�1Yc�t2.�..�
S1 S-t� p�4 P��2i �p �ti t ta (�cvQ Co�'D rs-► Qa ,
EHS 1"��QSL1C.\L. A- Sttic�
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N e C.�u r I i e l,J i( I� arrs . .Tax Map #�3.I Paxce� # I(0 5
S b ' ivn Section/Lot#
S-1=o3 �
Authvrized Sta.te Ag�nt � Date �
S�►StEfM L1011t�1OflBflfS t12�1i18S8lZt Q�Jp1wl�IC{lStQtB COl1L�t6i3 Of1 y. The contmcior must, fla� the aystem p�ior to '
beginni�ag the it�stalda�ion to irasur�e that pro�iergrude :a mdintai�ed �
� ' i�'
� � �Calc : ( =50.
0
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DF ScP�%c. cx m;�,,�►u,,.�
S(7� • FrpM C��c,K, '
� Kcc..Q c�l� Part,s oF Scpt�c t'
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Fr�M ba�e,,,,�cnt ec.�t.
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Tax Map #: i� �J) Parcefl # I � � 'g'ownship {-�u �d I t, � (Yt �' 11 S
�P�� ,�a� 1 i c (,� i I I i am S
Subdavlsion: Seaxaon: �o�
Locati�n:
'I'�e of Wa�r Saa���v:
��c�uireffients:
�/ Individual
Si.t� Approved bp �%/�'./�i �''�/` ��
Gmuting Apgmved bp ��''� -�S �/-�
��]: j.,og �S 5 3/z �'�n�
Well T S 5 3
.Asr Vent S 3 s �
Hose Bib ,�_ 3
Concrete Slab 2
w. � i II �: �i ti..c'
Commu�aity Public.
. � - .:..- . _
Well.�iproved. �3r: I)�.#e:� 05
'�°5ee Attadae3 Site Slcetc3a'�
Wells must be 10 feet from property liaes.
Wells must be 100 feet from septic systems. �
WeDs must be at least ?5 feet from anp bulding foundation.
o�� �on��ao�: �n5-E�. ( ( (,J�- � ( i n � A�r«, S�o�,�n . .
PC�3D, rev. 09/07/Ol
Dr��� �D � �
���;Sf ���� �� rr�
� _ -` c� � �LT1�T'IC� � �° �
���a���.�.����:a ���.��.�. � �� <3 �l � ��/
Owner: Cc.CC.� t
Location: � �
Subdivision:
/ Grout Log /
� c� l�a'wL S Tax Map/4� � Parcel # lo.�
Lot #
Well Go�qstraction
Distance From nearest Property Line (Minimum 10 feet) � U
Distance from Sepric System (Minimum 60 feet) /C�O
Total Depth: � Ll� ft Yield: l U GPM Static Water Level: �� ft
Water Bearing Zones: Depth �_ ft f a.�ft ft ft
Casing:
Depth: From �_ to �_ ft. Diameter: � in
Type: Galvanized Steel .-�
Weight: Thiclrness: /p � Height above Ground: l�/ in
Drive Shoe: �s No Any problems encountered while setting casing? Yes �o
If "yes" give reason:
Grout:
Neat: Sand/Cement Concrete GraveUCement i'
Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured _� Depth � to �. F�
Materials Used:
No. Bags Portland cement Weight of 1 Bag Pounds
If mixture (sand, gravel, cuttings) — Ratio to
ID plates: _�Yes _ No 4 x 4 slab �es _ No
Liner:
Depth: Date Installed: Grout: Installed by:
Drilling Log
Location Drawing
From To Formation
Q � L% d
c
7 o s c -� � �
� o � �.
. a�� „�-�`c� � ' �
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I hereby certify that the above information is correct
by the Person County epartment. ^
this well was constructed in accordance with regulations set forth
ID #�� Date �`�% 'Q c�
`-' LJ Pump Installment
Pump Installation ontractor: State Registration Number: f���
Pump Depth: ft S tic W�ter Level: 5� ft �
Pump Make & Model: 'f------ Pump Size and Rating: �_hp �U gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of ttu�r���as-�n p�e�ri�i to the well owner. .
Pump Installer
Date: �� �Q-�� PCHD rev O1/27/04