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A31 173Application Date: � e� �-�� � Amount Paid: J'Q , �7 O Receipt#: 3� 0 1 1�- �--���,5..� ������ - �"� _ � � �CJ" ��T`� ~�� IE.=�,,.;t,,.-���.��: �bz.�...,��._.�.Rn-n.z.�..71. 7E.-=7Ia.�.u.,.11a::lkT. . Application for Services (Sentic Svstems and Wellsl Services L Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 d) obile Home Replacement or Building Addition -`� J� $150.00 (if site visit required) � 5 ` C Well Permit (New/Replacement) $225.00/$125.00 Tax Map: �b � 1 Parcel #: ��;a yUT � equested ❑ Construction Authorization (Fee is de endent on the e of sy: Per��evision J 0 ❑ Repair of Existing Septic System No Charge Important: If the informatinn i�: t/ie application for an Improvement Permit is incorrect, fulsified, or the site is altered, tlien the Improvenient Permit and the Authorization to Construct s/tal! become invalid 1) Services Reyuested Name: Address: ,�� r� Phone # (home): 3 3 � - :�9 � ' I v � o (worlJcell): 33Ce - .�9 2 � I �l � 33�- �92 - 00'1� 2)Name and address of current owner (if different than applicant): Name: Address: 3) P�operty Description: Lot Size: , l.l Subdivision: /V f� Lot #: � Address and/or directions.to Property: /.S''7 —� (�7 �n� G1r-i � G�auc Cik[2�+ Qd `—� (��SS �rldAL •----� Lh�,� cr� -��r�-� Oas-� � 911> . 0 ' 4) Proposed Use,and Type of Structure: Residential ✓ Business/Type: Other Number of bedrooms / Number of people served (seats/employees): Z Basement: Yes N� (with,plumbing: Yes No � Garbage disposal: Yes No .� 5) Water Supply; = Private Well �(Proposed Existing_� Community Well: Public Water System:, Are there on the adjoining properties? No �_ Yes (please show location on site plan) Note: A comnleted apnlicatio�i must also i►tclude: ➢ A plat/site plan of the property that shows property ciimensions and tlze size and location of all proposed struciures. ➢ A signed copy of the `Lot Preparation' form ver�ing tltat the property is ready to be evaluate�C I am submitting t6is application to request services from the Person County Health Department. The information provided is accurate. I understand that if any site is altered or the intended use changes, all permits shall become invalid. � Si n r Ow Le al Re resentative : /e�/L'�' G'J Date : .3 ��% g atu e( ner/ g p ) 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) �� j �� / �,..� ..� / RUPERT E. A�OORF �� _ ...� ,. � , „� � .. _,� �, _ , ��, - - __ _.___ ____ r�' r�° S� � rt „ --�__ , '1'- _ -�-.� ~ �'-- _ ` ---_. )Idi FtU!_ )RNER --_ I ~ � `'-- -. �`'' -' / �, � �j� � � - _ i _�_ ' ���°, d�� —_ —__ � -� — ---__ � �-- ' 3 . I ���� � Y I ��L�� �� �. .y� 1 1 � � � ��� � � ���� 1�an.-sn.��„-,, ,,-,�<e��.�.11 I���.�.11�a �T�x f41a� ! � �r�c��l � Su;bdiivisian Ph �:5 e,tS ecLt i�,a,n.lLa,t � P�x�mit �alad �or ��'i Type of Facility: Pr�v # of Ocsupant5 p�_ Proposerl Wastewat�eer Sy r Proposed Re�air: � Permit Conditions: Owner or Lega1 Represe Authorizeci State Age� �� # of B ][�proveuYent.�'ermit I�To �piration New �Addition . ,s _,�L Pro}ei�ted Daily Flow • 3%n l� g- ��� s����y Gr%1 .- � , � .- , . Date: n . � The issuancx of this pe�it by the Health Departmeut in does not guar� the issuancz of other peasrits. It is the �esponsib�ity of the . aPPli�P�Y owner m in sure that all Person Countq P3anniag and Zo�ag and Bui7�ding Inspections req�emenis are met This improvement Permit is sni�ject to revocatlon if ihe site plan;`plai�'oi'the intended use cLanges. ihe imppovement Permit is nu� a�ected tiy a c}iange in ownership oi the property. This permit was issued in compliance with the prnvisiuns of the Narth Carolina, .: `Zaws and Rules for Sewaee Trea�nent and Drsuosal Svstems' (�5A NCAC 18A .1900). Neither Persop �ouatp•: �to�*�:tiie-` '� � Environmentai Health Specialist warranis tha# the septic tank.system w�71 continue to fnnctian safisfactorily in the fntm'e'or:tliaf. the-w�ter supply wiII remain potable. • � _ • A�nthoriz�iion to Construct Wastev�ater Sys�tem (ktequ�ed for Bn�ding Permuit) * See site plan and additional attachments (_). � � . -. Proposed/ �astewater System: � • - SQil L�TA� 2%��-� � d,/ ft4�.�.d. New �/ Repair Expansi . g P . _____ � o Basement Yes N Type ofFacili1.y: r� �Sir�-P. _ _ . �iaste�vate� 5yste�m A�equirements 'aank Size: 5egtic Tank:' DOd gal gnmp Tat�c: voo gal Gresese Trap: �— gai Drainfie�d: Total Area: � sq ft Total JLength ,�� ft ' Nta�mu� Trench Dep� � im Trenc� Width �_ ft 1VY'ini�nm Soil Cover. _� in IDist�ribntion: �istri`bution �oa Seriai �istY�ntion Speci�cations:. � �. State A� Permit ��� Tremch Separaiion: �_ �t e.ssttre 19�ianifold . Date: .9- 7s/ �M.wp The type of system permitte3 is Conventional ' Acc ted A'lternative. I acc�t the spe�ificatians of the perm�t. / Q � G9 L ,, �e�f�,��l �a�a-�s�ntatave: ,c�tl - Date: �r � o % ' pC� rev. l l/10/OS_ � . . . . tl _ � ��r---��4 )��J,� ���� �11.. � �..r•. ~ �l� `i...J � � � � � � �rn-•v-a�-as arn.y.�cn�+irn. �.+�u.�. �� �•m.Il¢� NEMA AX Simplex Contml Paxul �" S 4" Pressure Treated Po�t�j i Slopad To Shed Water 1Z' Sap�ra4ion � Electrical ConJui.t � , . •� .r . • "'; •• • . •: • . • . � 6u Cov.r • Acce�s Cover , . ' , , 1 , • , /�, •• ��' j� ,�, � ' � �, ` � � ♦ t j � ri• • �' . • � � , Opex�ins Filled Wit�{ � . �{i Siphon Hok' � Ix�et From S4ptic Tank poi1� �ament Cnout �� g�) a° SCH 40 PVC Pipa '� � ' � Check � Vi1W High Water Alarrn Level (6" Separation) Hish Lev�al - Pump On --._.�_ ' ' : rVaporLock . . •, • '. � $" Hok _ . , . � DrsNda4m �Up iiill). • ' Low Level -Purnp Ofi -�^""'"' � �_' � . . ,••� T�:�x M-���� � F'�arcE;.l t� Su,lael,ivi5ioii Ph��sc'Scsct�.iniiLr�t � Ihut Se�l Hotk Conexata Ri�er ' Endi Of Tha Coa�bxit • �-` ��� lY+� . � � � � ' �� ' IS" Sapaxation '�'hra�ded �ate Yalve ; Union , , � � �,� .,:• r ;� . ;�,,;,,_...-PoxtlandConcrotaGraut • � i� �d7tIC • - � .:� � � . Zip Cvni �. ��� .� Op�xing Fillad With T� SupplY '. Portland C4ment Gront � Lira • • ' � 4ntkt To Dists�bution .�N„�„„ 2" SCH40PYC Pipa ' �.; ' Preca�t Concrete Taak � 4" Concrrte � � ' •�;.; Material St:e h>3500 PSI Hlock � ,.`•.... : � •� � � - '. a •� , • � �� ° ' F1oat Wuu �` � � r • i FJaab .�: �Itamovabls '��. F'loat Trao , � . ,• ; :.. r � , �. . • '_ `iL 1 '.' . ��Dev GAI,L�N PUIVIE' TAl'ZK � . u �jo G.P�l�l3' �i eac� ���. f� I�I�I�.� �� �- � � ��°�� 1[ �Rn-� ,�n-.caanaan��ta�E,cnll 7HC�:.m.a,Elln Owner: TaX Map: �i 3 I � Parcel #: ( �3 Date: Line Tap # Dia� 1 2 3 4 5 6 7 8 � 9 10 Tap (Sch) � Tap Flow � Line Length � Flow / foot Z � 3 3� ft of line x 65 al. per 100 ft= �v ;' 100 = z�gal 75% x gal =� gal per dose �� gal per minute (gpm) = Flow Rate Frictio Head _ ' Loss: • 1�i ft per 100 ft of supply line x'`��n0 ft of.supply line =100 = . 0%g ft ft x 3.2 = �� 3 ft of friction head � iVlanifold Size: 3— y " Force Main Size: Z" pVC �� Total Dynamic Head =�Q_ft of Elevation head +_�ft of Pressure head +�_ft of Friction Head = �_TDH Pump Requirement: _� GPM @ � 3. ft of Head, Drawdown: �_gal per dose ,—` 2l gal per inch = � inch drawdown per dose � t' �%� ' 1 1 1 11 : 9 1 1 � _ - h � _� '������ � � • o i � , I �: � I I l I � �[(�)1�00�� i�l 1�1 ({1 1�1 i�ii�ii*i�*iiii�����ii:i�i��iiiii .... ..... .. ... ��:i��:�i��������:�.������:��ii��:�:�:� I 1 1 1 � : � _ ' "' �.... . _ • '" ; . ; Y. 2� �II Schednie 40 P� 4a�oQ -..:.;,r_=.:.;r,•.:r:sr.:�s.-: -,:.:..;r=� � �-� s . Sfze 3" 4" 6n anifold Size / # Taps Max DTo. Taps off one side ednce b 1/: for ta 'n both sides) i"te s 3/�te 1'it8 4 Z . 9 5 3 16 9 5 40+ 21 l2 �� � " Flo� er Tap �- Siae ii2cuerial Flotiv GP�i�! ;=" Sc1�ed SO �.S ;: " 3ched 4U 7.1 '/, " Sched 80 121 3;. .. c,•vAd an 12. � hl8 Fi ° U 1' 41 "�..m,..,,�...,�..�....�m........_... �.W _.. �..., IF _ --._u -Y m°".`.j 46 .7? -. C(iId i f;i)t.. �'"'�"`���� � CUf�hdEF; v � b; Y'��1Q� ���� — 3�0 . .�,� 3 � 9P " 330� � w Pu"� ���7' n ,. ' ^ �� f L� ��� _.i .. I 2"L.6' �.�:-.. ' � -- �- —�.'_ _ _ � r° s'k 7 r r 1 —.�_ � „``-- _ ----_••: _ IF � I� w cv u� i� <`J i•� 0 z -�m"'� - .. _ _—�._ __ NF �� � �p �� ' N -- --� ..,.�- ` `_' ` i �� f`�78 `�F8 ��..�,,,,.�,j,�.... " '�-- w..`5 "".,�,4......�,�. . ~' I -----_. � ° � � �' �� � -- __ _ - _ � �--` _ _ '� �� � � ,::� � _ ��_ � I -�. _ �� �'` � SCA�,E ; � -30 � - . __ I , � - -- - � -- Y ��� � . � � l�. i_�' � ���`�r 1„��� . � �•_ �y+ �• �:.J �.J' `T+.T.L. V '� ��T ��.-�-�a�.-�-*r*+ ���_�. �`��.�.�.t�.�. �}x M t_ �r. Su:aaiv�isian - k� ;as-?'� c�1� �i U n o T o�" e�d ra;� , , .s � •�. . � � _tw �': .`! �. ll � • ! �(_ ,� b " . � , . r��l � l� . . . .' � S stem T e in Ac�rd c,� ' . . `��� . : . Y . Y4� � � W�h Tatal� 1fa�: -_ � �F3�._ . TH15 SY5"1'�14A 4�S �E��i Ii��5TA1.i.Ei� � iM �tJ�IPlJANG� Vi11iH ��k..l��U..E �I�i�TI-t .. G'Afa��:1.9�, C�d1Ei�RL Si�,,"�UUTE�, t�UL�S F�R S�IA�GE i'RE�,T�1��1'�' A�[C) DISP�7SAL; • A1�D A,L-i. ��Al�Dii7�N5 •�F '� 7HE 1�A�4��3i�f�i° P��17 Ai�� C%��da'iT�UCiId� • �AlliHtai�9�ilC3iV� . � - . ' ��� _ . �� . ` o �� �� � : , ' � . : PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT 3-��-�3 II- 2�- 07 � � Date of Inspection System Installation Date Tax Map Parcel # Property Instructions: Check yes or no for appropriate items and explain in space provided for rerrarks and comments. If an item is not applicable, indicate by "NA". If an item is not or ca�mot 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 cazried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infil�ation and surface water diverted ? Septic tank needs pumping ? Inches of solids:�_ Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alazm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? Incf�es of solids(pump/dose tank : Elapsed time readings ? Counter readi�gs ? Drawdown rate: YES / NO ❑ � Ly � ❑ ❑ � � DISPOSAL FIELD: Evidence of efflueni surfacing ? ❑ Evidence of effluent ponding in trenches ?❑/ Surface water effectively diverted ? C� Diversions/swales properly maintained ? ❑,. Vegetative cover maintained ? [ Protected from tr�c/unauthorized uses ? �j Distribution devices in good condition ? [vj./ Field free of settled or low zseas ? [�� / / / / / / / / PRESSURE DISTRIBUTION SYSTEM: Turnups,lcleanouts/valves/taps intact & �ccessible ? � � ❑ Pressure head properly adjusted ? / ❑ COMPLIANCE: Compliant Non-compiiant Nezds Maintenance ADDITIONAL COMMENTS: EHS ���h'�( �t'!� u ■ ■ REMARKS �. . �� � � ll I � 1v;3 �.��. S.� 1� .iLa��'U�l� � � �71�'IC`� l�ara�vaz-�rs�sascaas.�a.��e-3 �3la+w.JlE�s a W �,d �. GL � �'% l�� !�U � , .._ �. a 3 f ,,.,�.,_ , , '� � ..�sL:��: ..la�s� �. �c.:l 1 � � �� �'- _�� ..�.�.�.��....�... j, , Groat Lo� Owricr: _.�.f.��. i_..� 1`__�.�5 ._ ._._ ..._ rax l�c.p.�. P.rcei �V _L� Locuion: Sui�divitian: y T � �� � Lot �i � Wdl Go�etla►a Diotsr►ce From c�esreat Proparty Lme (Minirnum 10 fot�l,) D�otosnce from Scptic 3y�tem (Minimu 60 fq et} Toui Depth: ,�,�,_ ft Yie{d: r,�_ dPM 5utio Wst+er I,�vel: _,.,, ft Wsttr Ficnrin� Zone:� Dapti� 1,� f� �7b ft ft tt Cada�{: Depth: Srom _ t2__,_ ��,�� tt. Dirmeter: �,_,�_ in Type: Gatvs�niud St�eel " Wei�ht: ��� Thi�:lme�e: _ I X�[ Hei`ht abcv�e C3rouad: �� in Lkive 81�c�e: _ L�Yt.s No My problem dteeuuntered while �ttir�� ca�in�? _Yee . No [f "yr�,• �ive resocm: __ _ _,__ Grsait: � I�eac: SsndlCeman C�ncrett (}�aveUCernent Annulor Spac:e Width �u�ches Wa�er in Atu►ulsr 3gace ~ Yea .✓No Method �f C�rout: Purrrped __ ..___ Pret�u�e _ r/P'auted _____ L)�pth �� to �,b _ Ft, A�lsi��i�k Uwd: � No. B�ge Pcxttand cemcnt Wei�ltt af t Ha� �� PoundY If mixture (atnd,�u vel, cuttin�) -• R�tio ,,,�,�#o ID platea: �� a, Na 4 x 4 tlsb es No i.tier: ____ .�..._. �� ._._ ._ Date Installed: „_,,,_,_ Grout: _ �.....__ ln�tailed by: �___�___,_._.r__.... . -- �w�� �� LocNtbn Drawl�� I hereby aertiiy that the sbove ;r.formatian si correct and thxt thi� weU w�` constructed in accc�rdAnce arith re�utstion� �ec fa�tt by tlu Pa:on Caunty Health i�r�rnnt, , ; S!$s�aturs of Cowt�setor � __,,, P� Inatalbn�nt Datt .,�- 1.� a � Pump Installotion C'c�ntrtctnr: Stak Rs�i�tsecion Numhcr: Pump Dtipth: � . ft Static Wattr Le.wef: g ' Purnp Mn.kt �c Modci; � � p ;� .... ___..._.__.,_.-- tunp 5izc and Ra tn$- .. � _ _. _ �p ..�..__� YP� ([ harcby ccrtify ticat thim pi�mp w�a �netstted srid the well h8ud oomp�eted eccording to tha i'ara�on County Well Rulas ii� c�tocc °��n rhis datc �nd that a co�y of this recard has bccn pt�ovidcd to ttte wrel! owncr. � E'amo tn�tall�r Si�satqre D�ie: P"C'��D rev i�S/27-��a ..• :.. : ''�•" :'�. A i, "..r i• . .. � � �.��� �t yF;'� '� •; • � �S S �, . ���-�� ,���,�"�` '"�. .� � :'�'f£��� Y < �,��� " �! • � . �``+�''�'�" �a -^t �' �, .+. ' :�":•7M"K'�w,.,'"":��t.++���S:��YF�i�^�7�w-��'-�<?�"'�'+-� , ' . +r�••� rw .•��Yi�.i wI�T•� � YY i:i�LiY � • � , . i31..iYLCiYYY 1�76Y�iL ��� �iJiii� �� •7.YiY.iL� i7HSJQ1 �9.��J � � . � .� T� �� P� # l 7 r�p: A�plican� �ado, P�i n� , . 4ni�ivi�--� . Lot # � ' , ✓ • . .• � � �'�a�a �p�': �ndt�i�l _ Ca�y Public $�lu�em�ts: ` • Sito A}yprovcd. Hy: erouting Appamvcd By: Wo11 Lo� PmonQ Tag:. .� W t � � Well Ta� � ori Air Vea� ' . H,oee Bib= • . c��� . c� s�: . . � �all Drs�le�: E✓a,� s .. Well ApQ�oved by: ��,n x, � o� . ��'�'9ee Atta� Site 3�**** . . L�inar. . . �b�etallod by: ' D�pth set � C�rou#ed: � Date: ' ' • w� s�e: - Dat�:�1��� (�-7 _ . W� 1i1Y0� t7G lO SGG1 �� Y""J � w� � be ioo �c �. � sy�. � �v� �t�� �.� a� �t��:�y v�a� ���.. , . o� ��• i , . �c� � o�rfo� ;. 0