A32 141� The District Health Department
( Orange, Person, Caswell, Chatham, Lee Counlies
`� Water Supp�y ar�� Sewage Disposal
j' IMPROVEMENTS PER IT No.
j� t` i�, 1'' -�f .: r. D�e l� `- `�� `
�x Owner: '
' � ' � .
� Location: ✓� `� d �`r t, t. �t .�i t' ; ,` 11_r _r� �-_ t .
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p, Contractor: - � .
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� Water Supplp: Prijj7 ate `''��� Public
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Sewage DisposaY Faciliiies: No. bedrooms r Dishwa e Disposal,
,washing machine;j other automatic appliances _ �
,_ �;
Size of ta� nk: ^� "f � �"l� Nitrification line:t '�' � r ' � ��
�; ."i _ •,' � ' `_.� E-' _C • `��:•c. ;�'f�:..v � t y •.S ;: r►a I -: ,
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years and shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTIi DEPARTMENT
STAFF BEFORE ANY POftTION OF THE INSTALLATION IS COV-
ERED AND PUT INTO USE.
�
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Date approved: - �` ��" , Signed` '"�-^� i `' �
- _•Sanitarian % 1.
Well: �' / -
S age Dispq�sal: Counter-
By: �.j �I f signed
(Owner or his rerresentative)
Certificaie of Completion • � <�L-�---
Date Agproved: ��'�/�By: �' �'`
� a itarian -' � �
(OV )
Location of well and sewage disposa facilities sketched on back.
NOTE: Make sketch of installation showing lot size and shape, location of 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.
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Applicant:
Location:
Permit Valad fo�- �Fave �'e
Type of Facility: $
# of Occupants # of
Proposed Wastewater System:
Proposed Repair= _J�
Permit Conditions:
C
Owner or Legal Representative 5
Authorized State Agent:
�x M�p � P�;rc I #
S�ubdivision
Ph:�s .Sectian: ot #
� I�aprove�e�t P�r�t
I�To �zpiration
New �. Addition �ater �upply �� �
s � , Projected Daily Flow 3� g.p.d. �
c�t 7 .
� l,�ea s�
Type: �
Type: .�
Date: / �� �d 3
Date: - ��
The issuance of this peimit by the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicanbproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. T�i.s
Improvement Pet�mit is subject to revocation if the site pian, 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
Ru1es for SewaQe Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Per§on County nor the �nvironmental Iiealth
Specialist warrants that the septic tanic system will continue to function satisfactorily in the future or that the water supply will remain
potable. �
Author�aataon t� Cons�uct Wastewaie� SysteYn �Requireai for �uilding Permit)
* See site plan and additional attachments (_). (.'���'�
�
Proposed Wastewater System: �Z —ItL+/ Type � Wastewater Flow �QD g.p.d.
New � Repair Exp ioi 3 Soil i.,T�: ��SS _ g.p.d./ ft 2
Type of Facility: � �i � Basement Yes � No
Wastewater System �tequire�aents
Tank Size: Septic 'Tank: ��� gal Puffip 'Pank: � gal Grease Trap: gal
Drainfield: Total Area: (f��6v sq ft '�otal Length 3�0 O ft 1��Ia�um Ta�ench I➢epth �
T'rench �idth �� ft l�inimuan Soil Cover: �D 'aai Minimum Trench Separation: ft �' e'
Dista-�lbution:
Spec'aiicataons:
Distribution Box Serial Distribution
Authora�ed State Age�t= u��i�~�
Permit Exn� on Date:
� Pressure Manifold
�
... .,. _ _ ,
Date: -l�"� � �
�
The type of system permitted is Conventional �`.�- Innov ive Alternative. I ac ept the specifications of
the pexmit. � ��
�wner/�,eb�� �e�rQsent�tfl��e: Date:
PC�-ID i/17/2003
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�ITE SHETCH
Subdivision
��
A . thorized State Agent
T� m�P #.�? . P�� # l �tl
Section/Lot#
R-��o�
Date �
System components represent �approximate contours only. T'he. contractor must f iag the
system ��rior to be�innin� the installat�on to insure that t�roper �rade is maintained.
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i'NIS SYS'TE3N MAS• BE�iN iNSTAL",1�.F� IAi 4`D��PtIANC�.'1lIt�TH APPLICAB RTH
CAROL.YNA GEAIERAI;..STATUTES, -RULE� �E� SEIfVAGE''FREA.TII�EACI' AND i�f.5F0�►1-, .
AAID Al.1: CONDtTlt3l+iS� . OF . TI3�. lMPft�V'�lEid'T� P�Ii' AND. •C�NS�Etl.1C�1�[°+�i '
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PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MO1vITORING REPORT
S� 7-I�} y-ao-ay �riA6 A31 ►`�1
Date of Inspection System Installation Date Type Tax Map Parcel #
3ia. �.rtLo� Pa�c%t,-tt.'k4 �-��ta� T�� , ��. ��S y1
Property Address
Instructions: Check yes or no for appropriate items and explain in space provided �or 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 cazried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infi(tration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Requ'ue3 pumps pres�r.t & functionai ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ?
Inches of solids(pump/dose tank):Z�3
Elapsed dme readings 7 lS Ac
Counter readings ?
Drawdown rate: �1
YES / NO
❑ � ❑
■ ■
■ ■
'■ ■
■ ►:
c� ■
DISPOSAL FIELD:
Evidence of effluent surfacing 7 ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? �
Diversinas/su�ales properly maintained ? ❑
�eget3ti�e cevPr n►aantained ? �
Protected from tr�c/unauthorized uses ? �
Distribution uevices ui good condition ?�
Field free of settled or low areas ? �
/
/
/
/
/
/
!
/
�
❑
❑ �l�
❑
❑
❑
PRES�UtZE DIST�UTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible ? � � ❑
Pressure head properly adjusted ? $ / ❑
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
►_�
■
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REMARKS
S�f'i'1C. "r�►�1�, t�1dT f4Lc.�,sS►Q� ,�v�
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nrii�iTiviv�'w Cvivilvir,idTS: ��E `Z'Aa•\�S l�'��'+4�fl �(Lvc►tZ,. `70 �'4'� c�T
5 - `1F�t� �,�,s��va,�, ' �Nacv C A;�ttx�-• 1� �P t��4 ; 'R�cc,o�.+�►100
A 1�D�c�t�O �sSS II�SC�S —s`O S�'�L. TiA�\�,
EHS �F,�%�.lC�, �. St`�iT�
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�'�SE SEE l�'I"�'AC�El) P� AN FOIt �I.L. SI'I'�E �'�OiJ'�
Tax Map #: � ��' �'azc�d # � -c 1 Township
�PPlican�
Subdivisiori: Se�tion: Lot
',G � �f �C� �� �7_ �,�" �� � ��-�-ci � �ir
'I'�e of Water Sa��AI�: �,C Individual Community Public
Re�uireanents•
Site Approved b ��� �, j
Grout�ng Ap oved,bp i
Well Log
Well Tag;
.Air Vent �
Hose Bib
Concrete Slab
Well �riller. ��% �'^ S
Well Approved �y: Date:
�See Attacflaed Site Sketc��`
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Odier conditions•
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PCf�, rev. 09/07/01
us,cs,zuo�i iu:�i nr�:
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D. �te � r��1�c��1
i�Tell Log
p��; � j �� �i � �.- � Tax i�1ap �Parcei # �
Lacahon: _ � rd �t �'%. �l-r YLd�
�L1�1Y1S10A; � �n. c4 d'{�' F,��� n �t� �f�.'7�[ r �C #
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`�Cll �0t93I1'fxCtlOri
L?istance From nearest Property Line (?�finimum la feet) �--
Dists�nce fram Septic System (Minimuffi 60 feet) �
Totai Depth; � ft Yield: v? � GPM Static �Nater Leve�: __ � 6 fc
Waier Beari.ng zones: Depih l� d ft�$ ft ft
Casing:
Depth: Frorn �� to �/ �-y.� ft. Diar.�c�tsr: d` in
Type: Galvanized Steel `� �
Weight: �_ Thicl�ess: l� Hei�ht above Gzound: �,i in
Drive Shoe: �es No Any prat�iems encountere�i �bile setting casing? Yes �o
If "yes" give reason:
Grout:
Neat: Sand/Ce�ment ✓� Concrcte GraveUCement
Annular Space Width ___��____ inches Water in Anmalar Space Yes �`�4r
�Iethod of Grout: Pump�ci Pressure � Paured +� Depth to
Materis� Us�d:
No. Ba,�s Portland cement Weight of 1 Bag �_ Pounds
If mixture (sand, gravel, cuttings) — Ratio _� to 1�
ID plates: __ Yes _ No 4 x 4 siab �es _ No
Drilling Log Lac�tis�n Drawin�
Ft.
I hereby certify that the above information is conect and that tbis well was constn!cted in accordance�with regulations
set forth by the Pe:san County Health Department.
Signature af Cmntractor -7' ID � �v 3 � Date ��. � �{'—r `T
PCHD rev 01/16i02
.
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