A32 256: °� ��I G
Application Date• �
Amount Paid: . a,00.
Receipt #: _ � (, %�6 �
�i12#I�C' .
j�Improvement Permit (Site Evaluation)
$204.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Buiiding Addition
$150.00 (if site visit required)
� Weli �'ermit (jVevv/Rep;acementr'Repair)
$300.00/$20G.00/$75.00
��� sf ������T
`_`, ��-�- � � �J�T �°�Y
�.uno nn-xD,rr,.,�,.ac�and,tu..� ).�a3.�.Il�,�ia
tion for Services
Tax Map: /4 3�
Parcel#c ��S(Q
��a(aa(-ec� S` Z3'� �
Services Re uested
0 Construction Authorization
Fee is de endent on the pe of system p�rmitted) �
❑ Permit Revision
$75.OU
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Inf �mation:
Name: � �0 ��a ,0? AYa'
Address: /22 f{1(' ovv �CA.� ('f. /ZOJLbo�r� �_
2't57 3 �
2) Name and addr s of current owner (if ifferent than applicant):
Name: �j� ia �'GtYO�N n ��f n'c�e M�nK
Address. 'L2 �ruhv�� S�. �� /�(L
?,'l5� 3
Phone (home): �33 � � �jq7 - �J lo � 0
(work/cell): (�3Cv) SU3- Z13/
Phone: (33(,) 5 �9- 5 �$5
3) Property Description: Lot Size: �� Subdivision: Lot #:
Address and/or directions to Properly: � 57
Ai' r ' I ¢� G . .'� ' hf ic . Ra�Gµ
❑ yes no Does the site contain any jurisdictional wetlands? . � otK /.k,�. �j�Z•�p�y�,ds �h �'�gl/l�
� yes no Does the site contain any existing wastewater systems?
❑ yes no Is any wastewater going to be generated on the site other thar, domestic sewage?
❑ yes no Is the site subject to approval by any other public agency?
❑ yes � no Are there any easements or right of ways on this property?
• (if `yes' is checked, please provide supporting documentation)
4 Proposed Use and T3-pe of Structure: ,
Residential
New Single Family Kesidence Maximum number of bedrooms: �
❑ Expansion of Existing System If expansion: Current number of bedrooms:
� Repair to Malfunctioning System Will there be a basement? ❑ yzs � no Vr'ith plumbing fixtures? ❑ yes ❑ no
❑Nan-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum numUer of seats:
5) Water Supply: �New well ❑ Existing �Vell ❑ 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 ❑ Accepted ❑ Innovative ❑ Altemative ❑ Ot�'�er ❑ Any
1 cert�� that the information provided above is complete and correct. I ulso understancl that if the information provided is
inaf,cae�te� ijihe site is su. sequentl�rlte,�ed, or the intended use changes, all permits and approvals shall be invalid.
Signature (Owner/ Legal Re�e'�
* Supporting documentation requued.
���
\ Date
Permits are valid for either 60 months or are non-expiring when accompanied 6y an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/I 1) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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�� (� ���� �� Tax Map: �� Parcel: 2.5�0
�,� * � � � Subdivision �t ,4
- �� (� � � �' � � Phase/Section/Lot # �
7E:e�.�n�����,m��.Il IL� ��.Il�II�
Permit Valid for: Five Years
Type of Facility:
Number of: Bedroo s /
Proposed Wastewater System:
Proposed Repair: ����.
Permit Conditions:
�(a�_�iYt.�r__.1�lc
Authorized Sta.te Agent:
(X) Owner or Legal R�
Improvement Permit
Non-expiring
New �Addition
t,s�4 / Employees / Seats:
Water Supply: �e( (
Projected Daily Flow: �BD gallons/day
Type:
Type:
Date: ��1�_
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 applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
lmprovemeni Permii is subject io revocation if the site plan, plat or the intended use changes. T6e 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
anr! Rules for SewaQe Treatment and Disoosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmeatai
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply vvill
remain potabie. �
Authorization to Construct Wastewater �ystem
�ee site plcm and additional uttachments (�
Propose Wastewater System:�,�(q� �, ou,,,,� - 25% � (*)Type��1�b,4 Design Flow gd gal./day
New Repair _ Expansi Soil LTAR: �. 3a gal./day/ft2
Type of Facility: Sin4�e �nM�lv Q�.�a�l�J. -�$R Basement: _ Yes _No
(*) System Types IIIb, Illhg, IV, and V, requireperiodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank OGb gal. Pump Tank DU gal. Grease Trap gal.
Drainfield: Total Arza 20o sq. ft. Total Length yDD ft. Max. Trench Depth � in.
Trench Width �_ ft. Min.Soil Cover �_ in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �
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Authorized State Agent:
The system permitteci is: Conventional
and specifications of this permit.
(X) Owner or Legal Representative: _
/Accept d pr ►' / Alternative
Issue Date: 5-3�_ r�Q
Permit Expiration Date: $-3f_21
/ Innovative . 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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--, � �O �CT�'IC'�Y
'-��-�������¢�u ���,E� Owner: Gaz�
Tax Map: A 3 2 Parcel #: 251� Date: 5-3 t-1 �o
�a�e �'ap �ap (Scb) Tap &'�low Line ��ng#ta �'low / foo�
# g➢iamete�(in) { m) • (fi)
1 � '
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9 28, f 2 =
�0 3���{ oa'
y e� ft of line x 65 gal. per 100 ft = ; 100 =?1QU gal
75% x gal = � a S gal per dose �_ gal per minute (gpm) = b'low ktate
Friction �ead
�oss:� j�,_ft per 100 ft of supply line x^�� ft of supply. line = 100 ='�I , 2'i ft
ft x 1.2 = 11_ ft of friction head
I�Ianifold Size: 3_ y " Force 1V1ain Size: 2- " PVC
iotal Dynamic II�ead =^-38 ft of Elevation head + 2 ft of Pressure head +,�_ft of
Friction Head = 57 TDH
��mp I�equirement: � GPM @ 57. ft of Head
�ra�down: �al per dose = 21 gal per inch =� inch drawdown per dose
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No. Taps off one side
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' F`iow er Tap
Sie 1Llcrterial �o��' G?Y!
!� ^ Sched 80 �•�
;. „ ` Scired �0 i.l
;y " Scl:ed 80 !0.!
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Sloped To Shed Water
tS� COV'�2Y •
i.,
Ixilet Fmm Septic Tank
A" SCH 40 PVC Pipe '
NEhIIA 4X Simp]ex Contml Panel
+1" X 4" Press�ue Treated Post
12" Sep�ation
Electrical Cox�dui.t =
T�x M�� ; ' �rcel # _
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Ph•�se:S�. tion�Lot #
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24" Mini:caun —;
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Threaded Gate Valve
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• � Access Cotrer• • ' � • j ;
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1 �• � . . 1 T._ br�
�,. Opening Filled With Anti Siphon Hole �..• Tiks
Poztland Cement Crrout H� i
— (Drnvn )
Check
• �Ialve �
High Watex .11ami Level '
(6" Sepazation)
High Lev�el- i�ump On -�,�
fiVapor Lock
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Rope
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f . �; =�A'Nn (IIp HiII) �
. Low Level -F'uxnp Ofi' �
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. Preeast Coxurete Tazilc 4" Coi�csete
� • � ;•; (1NfaterialStxengthy3500PSI) Block
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Concrele Riser
6" Sepazatinn
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Supply ' • • � �Pening F�led With
L� � : .. Portland Cesnent Grout
Outiet To Distribution
-- 2" SC$40PVC Pipe
Float Wirn.� � '
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Floati� ..
_Rexnovable • • �
F1�6at Tree �
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,30 GPM � -v�7 � � �
Tax Map: ��2
Subdivision:
���.sf ���.���
�- � � ����
]E������.m���.Il IE�3C�� fl�l�
Parcel: 25(,Q
WELL PERMIT
(New ✓ Repair_)
Lot:
Applicant's Name: J�l icel� Cnu�i-
Mailing Address: ZZ' ' � C+.
_h��ee�e . fS 2757'i
Phone Numbers: 33�- Sq�- 5��n 33�- so3-2131
Location of Property:
A�I,M K R,�I . ? (� .
�
7
P�rmit Conditions:
1.) See attached site plan for proposed well location.
Z.) All appdicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue. --°
4.� �ssuan�e vf a persait does not guarantee a potable water sz�ppiy
Other Conditions/Comments:
�{r�t,� Ci�� S�cKS
i �
Permit issued by: Date: � 3/—l�
1�1ew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additi�nal Com`nen�s:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
n....�,�... n�r ��c-r�
Certificate of Completion
Di.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
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SITE PLAN
Name�iCo� ��_
Suhdiv' 'on
�
Au horized State Agent
Tax Map #� Parcel # 25�
Section/Lot# /�I�A
S-3 �-lfi
Date
System components represent approximate contours on[y. The contractor must fiag tl:e system prior to beginning the
installation to insure that proper grade is maintainerL
T'�it..� Q�1�NIC
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f OvC�I��
u{ili� Po(1i �2St99
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3 :50 Feet �
ee.A.w�um�w.uanr�..5wvsc,-�rrrrvn.ahu�aracx M
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�° na�na^�n�n-3n��n�an� g'���.lZ��n
SITE PLAN
Name ico� C�+r`�'
Subdivis' n
Aut rized State Agent
Tax Map #�� Parcel # 251t
Section/Lot# lJ�,_._,_
_ �3/-/�
Date
System compene�:ts represent approximate confours on[y. The contractor mustJlag the systemprior to begin�:ing ihe
installation to insure that propergrade is maintained
Sni�'al St�s'�w,
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I���n������¢�,�1 iE-���,.Il�11�
SITE PLAN
Name ' Q,
Sub ' ision
,
uthorized State Agent
Tax P.�ap #� Parcel # 25(Q
Section/Lot# �J%14
�-3 (_11a--�_
Date
System components represent approximate contours only. The contractor must,/lag the system prior to beginning the
installation to insure that propergrade is maintained
3l4