A31 90Application Date: < <
Amount Paid: �.,D6 . 02�
Receipt #: 1 �D�3�c�
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�S�sa �� lc �f c.,al�.dc /�r�5l�.i AD
0
nit (Site Evaluation) �/3
00 (if> 600 gpd)
acement or Building Addition
$150.00 (if site visit reyuired)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
��,;,�f 11 Jl��� �� V Tax Map: !'� `� �
r..� �� ������ Parcel#: �
��"�.�ra�nn'rcnTM��*n*e3=n4:,m� )��c+s..U��.�o.
dicatian for Services � ��, ;�-� r(�t���" �
Services Requested � f �—
❑ Construction Authorization
(Fee is dependent on the type of system permitted)
0 Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: Na Charge/ CA $150.00 or $300.00
) Applicant Information:
� �
Name: L. i QI"�i 1�
Address: G ; B , �C
� '754� I
2) Name and address of current owner (if different than applicant):
Name:
Address:
,3 • 2l0 [�.U''�t5
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Prooertv: �1Glle �» r�
��
Phone (home): .33�0- 3r�t aa �o
(worWcell): 33l0'S03 'd.la Q j C7aWY1� �
�-q �q-a.18-11aa, C3� �ty�
Phone:
Lot #:
❑ yes 0'no Does the site contain any jurisdictional wetlan$s?
❑ yes E3 no Does the site contain any existing wastewater systems?
❑ yes C�+7��� Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes L�`If�o Is the site subject to approval by any other public agency?
❑ yes �7 no Are there any easements or right of ways on this property?
(if `yes' is checked, please provide supporting documentation)
4�) 'roposed Use and Type of Structure:
aResidential
❑ New Single Family Residence Maximum number of bedrooms: �
❑ Expansion of Existing System If expansion: Current numb�_e�r� f bedrooms: _�
❑ Repair to Malfunctioning System Will there be a basement? 5d'yes O no With plumbing fixtures? ❑ yes CE'no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: ❑ New well Q Existing Well � Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? [�7 yes ❑ no
%"` 6)l If �,pplying for `Authorization to Construct', please indicate preferred system type(s):
O�Conventional ❑ Accepted ❑ Innovative � Altemative ❑ Other ❑ Any
I cert� that the informatiort provided abnve is complete and correct. I also under,stund that if the information provided is
inaccurate, or if the site is subsequently altered, of• tlie intended use changes, all permits and approvals shall be invalid.
% a.�,�r-�� � � X _ —1�.�-�-
Signature (Owner/ Legal R resentative ) Date
* Supporting documentation required.
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.
�l0/111 Person Countv Environmental Health. 325 S. Morgan St.. Suite C. R�xhnrn Nf: �757� l��ti_547_1 �Qm
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)C�a�rn.�na����*TM�+� �irn.��.I1 �-���.Il��n
Applicant: �1
Address/Location:
Improvement Permit
Permit Valid for: Five Years ✓ Non-expiring
Type of Facility: P�v��,RP.S�i�r - qa �. New �Addition _
Number of Bedrooms I.� / Occupants / Employees / Seats:
Proposed Wastewater System:
Proposed Repair: w
P mit Conditions:
.�P1Q�_„_ �
�
Authorized State Agt
(X) Owner or Legal
Tax Map: � Parcel: Rd
Subdivision
Phase/Section/Lot #
Water Supply: 1n�e �( QK'�5��
Projected Daily Flow: �$D ga lons/day
�� Type: ti
Type: b
Date: � Z- /9-/3
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property owner 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 North Carolina `Laws
n�:d Ru[es for Sewage Treatment and Disvosal 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: )(*)Type _�� Design Flow ;{RO gal./day
New � Repair Expansio Soil LTAR: , 2� gal./day/ftz
TypeofFacility: Pr;�/cr�- P ir�PnCP_ Basement:_Yes _No
(*) System Types Illb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
,tf ,.�esd ed
Tank Size: Septic Tank DO gal. Purrip Tank 000 gal. iJrease Trap — gal.
Drainfield: Total Area I 4� 0 sq. ft. Total Length ��_ ft. Max. Trench Depth _�in.
0-L•
Trench Width � ft. Min.Soil Cover (.� in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold V
Authorized State Agent:
The system permitted is: Conventional
and specifications of this permit.
(X) Owner or Legal Representative: _
Issue Date: � 2-/�}- /�
Permit Expiration Date: /Z-lq-lS
I accept the conditions
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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� . SIZ'E S�TCH
Name � �_ Tax Map #�.Pa:�cel #�'�____ .
Subaivi ' ' ,_ � Section/Lot#
� . l2- �q -i.�
uthorized State Agent Date
System components nepresent ap�ir�aximnte �contours only: The caniracrtor must, flag the systemprior to
beginning the ifrstallat�ion to insure thatprolhergrnde is rrraintained �
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nsuring a healthy environment
phone 336.597.1790
fax 336.597.7808
325 South Morgan Street, Suite C, Roxboro, NC 27573
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NEIvfA 4X Simplex Contxol Panel
4" X 4" Press�u�e Treated Post � �
Sloped To Shed Water „
�� COVEY •
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Inlet Fmm Septic Tazilc
A" SCH 40 PiiC Pipe '
12 Sep�atwn
� Electxical Coxtduit --
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• , Access Cover• .� • , ' : ; ' 1 �
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�,, Opening Fi11ed With . Anti Siplwn Hole. `
Portland Cesnent Gmut (Dcxn H�1)
Check
. Valve -
High Water tLlarm Level '
� (6" Sepazation�
;;, � _. H�ghLevel-T.'umpOn -�.-„�`
: � � �Vapoz Lock
Hole �
•, � Dzsxda �n (Up Hi11)
• . Law Laval -Pump Ofi �-f"
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. Precast Cozurete Tank
' � � � ;•; (14YatezialStrength>3500
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T�x M�� ; F�r�cel # /
; �ihclivisi�on
Fli,�se:�� cGian�Lot #
Duct Seal Both
Ends Of The Coz�it
� 24" Muiincun -
Threaded Gate Valve I:
Union 1 ^� n
Concreie Riser '
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b" Separation
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• . POYtL311d COriCYE�B Cr70tlt
Mastic � . _ .
Zip Cord • � ' Oper'^g Fillad With
Tie9 Supply '''� portland Cement Grout
Line • • '
Outlet To Distnbution
�-Nylon 2" SCH40PVC Pipe
4" Co�te
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lE`::�-�a ��ffi��¢�.11 ]HL�@�.11�E� Owner: %� \R� �n
Tax Map: 3 Parcel #: Date: � 2-Iq -l3
1Line T'ap
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�'ap (Sc�) I Tap &'�ow I Line b��ngth I�'iow / foo�
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�, ft of line x 65 gal. er 100 ft = ; 100 = 312- gal
75% x gal =� gal per dose �� gal per minute (gpm) _�'low i�ate
�'riction Head
ft�oss:� 3 ti"1 ft per 100 ft of supply line s"' I Ibt ft of supply.line � 1q0 = y�ft
ft x 1.2 =�_ ft of friction head
l0�tanifald 5ize: 3_ `� " Force 1Vlain Size: 2- " PVC �
iotal Dynamac lE�ead =^- I S ft of Elevation head +�,_ft of Pressure head + S ft of
Friction Head = Iq TDH �
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P�mp Requirement: �(� GPM @ 2S • ft of Head
IDrawdown: Z3 N gal per dose = 21 gal per inch =_� inch drawdown per dose
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