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A32 39The Districf Fiealth Deparfinent Orange, Per�on, Ca well, Chatham, Lee Counties SEPTIC TANK PERMIT Date �' � � � -/ L `' t Name of owner: C i �C� R'T'11Q 11 '`� � 1`�� � Name of contractor: �� b G'ry'" '� �� i� fc`�� Address and Directions �r��� n ,., Person or firm doing installation: Address ��!7 C! f t�.� •�, r No. of persons to be serve� Bedrooms 1,�3, 4. Additional appliances to be used: Disposal, dishwasher, washing machine Recommended: Septic ta ( Nitrification line: �✓ � X �� Above recommendation based on information received and observed soil condition. Septic tank and nitrification line musi be inspecfed and approved by a member of the Dis2rici Healfh Departmen! staff before any portion of the installation is covered. Date Approved: � y� � By Countersigned Signe� Sanitarian O. David Garvin, M.D., M.P.H. District Health Officer (Over) � NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adjacent property, etc. Write in measurements in order that installations may be located at later date. ` � GGESTED INSTALLATION (Date ) FINAL INSTAI�I.ATION (Date ) ' ��t't (Road or Street) I �(Road ; r Street) �,� \� � i i i i i i i i i i i i �._� i� :� i i � i i i i Application Date:�� a�+ ~,� T� Map: � 3� � „ Am�unt Paid: c� 0 4� b0 .,7 - 3-) � Parcel #. 3 � . �_ �-�' � Receipt#: CYcd; �- � ..��� s�-_ ��II�.� ��T _ - = �'�- � � TC�� � � 7���'.ga-a>nu anaa��•�•�,�c�gn�rall ���.�x=,an.11��n Application for Services (Septic Systems and Wells) Services � Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) � Mobile Home Replacement or Building Addition $ I50.00 (if site visit required) ❑ Well Permit,(New/Replacement/Repair) $309.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 ) Services R�equested by: L Phone # n � Name: /�,lrC r,-,�,( (home): ,lG�/' .��G Address: //G��^� /�:_�/N �/ii/.r�'� (work/cell): ���s, y.�"/-�y�j' �� /e �il .�ci<_ z �.s�// 2) Name and address of current owner (if different than applicant): �.Q�'µ� •� Name: �oYr� Address: 3) Property Description: Address and�/yr directions to //.s�/�/ ,�f�,.�/c /�//f Lot Size: � �`"��itj Subdivision: Lot #: T G Z7.f� 4) Proposed Use and Type of Structure: Residential, � Business/Type: Other Number�of bedrooms .� / Number of people served (seats/employees): B�ement: Yes No L� (with plumbing: Yes No _) �arbage disposal: Yes No � /- 5) Water Supply: Private Well �Proposed Existing �/ Community Weli: Public Water System: Are there wells on the adjoining properties? No � Yes (please show location on site plan) Note: A completed anplication must also inc[ude: ➢ A plat/site plan of the property that shows property dimensions and the size and location of all proposed structures. ➢ A sighed copy of the `Lot Preparation' form verifying that the property is ready to be eva[uated. I am submitting this application to request services from the Person County Health Department. I understand that if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all permits and approvals shall become invalid. Si nature Owner/Le al Re resentative :�"`'"b �' Date : �,i/ � ( r r ) 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ; ��� � � ��J��.� �.11 � � �-' 'y1 j'���1 � �1 w �� �r,� � �'^ � � �l�! � 1!. :t �_.7t'b�'a.3Ccm�nrn �r-n^� �7L']1.�.51.� ��:�.�� �Plican� C �"�ilr' ��PS V �U hr' � S . ��rmit �alid for _ �ive '�e�s Type of Facility: S l[�aprovement �er�mit _ PIo �apiration # of Oco # of Bedrooms Proposed Wastewat m: Proposed Repair: Permit Conditions: Owner or Legal P Authorized State . . T�x Map � �rc�el tt S u�bd;i vi.s�i o n Fha�s�e Sect+ion Lat � New Additian Projected Daily� t 1� g.p.d. ater SnpP�Y Type: Type: ...��.,. Date: 2 < The issuance of permit by the Health Department in does not guatantee the ce of othei peimits. It is the responsib�ity of the � applicant/pro owner to in si�e that a11 Person Coimty Plaaning and Zoaing and Inspections requirements are meC This Im�provem t�ermit is snbject to revocation if the site plan, plat or the intenderl use chang The Improvement Permit is not affected y a change in ownersiup of the property. Tlus permit was issued in compliance with the p ' ions of the North Carolina Zaws d Rules for Sewage Trerrtment and 1)isnosal Svstems' (15A NCAC 18A .1900). Neither rson �ounfy nor the Enviranmental i�ealth Specialist�warrants Wat. thg septic tank system will continue ta function satisfactoril ' the future or�that the water supply will remain:potable. - _. : _: . � . tluthorization to Co�str�ct Wastewater Sys#em (Required for Bu�ding Perma.t) � * See site plan and additional ut�tachments (_ j- Proposed Wastewater `S� em: � '�L'9-< ��nt/• Type �� Wastewater F'low 3�-�:p.d. New _ Repair 7� Expansio _ � p � Soil LTAR: , 3�--. Z.� g.p. d J ft 2 � Type of Facilrty: , �!� /� S Basement _ Yes �, N� �aste�vater Systean Resyuireuaents Tank Size: • Septic �ank: l�JC9 cSgal Pnmp Tank: � 0�gal �Grease �rap: gal yAO �COKV �rai.n�eld: 'Y'otal Area: ^' %�dsq ft �Total Yrength �i� o-���ft � 1VIa��nm Trench Depth l$ Z� II► �remci� �idth 3 ft 1Vliniffinua Soii Cover: �p . in lYlinimnm Trench Separation: � fft �istribntaon: Speci�cations: I3igtribution �og Se�ial ia S2�P �/1 urnl� �✓LcL2�r � (9-C � 3 C� � Authorizeai State A.gQnt Permit E:m� The type of system permitted is ��Canventionai P��- � i�w�erlL�ga1 ��pres��tative: � Acce�ted l��- � Pressure Manifold c'L��c Date: Alternative. I accept the specifications of the Date: � 3 � PGHD rev. 11110/OS ConnectGIS Page 1 of 1 .� � __ �ti ��� :� .� e� ��, � � �� _ �� � j ' ` ,-�_ ; ` � � � �� ,-`� � � ^ :��,, � �� � � ,� � ,�^;., } 768 �: �� ,� � � � � �� .� _ � � � � � ,. �, ` � ._ \_1 . ' � i�i3a` .�. '� � � � ��> � � � � � �� `� � # � �'� �������' � � ��� � � �. 1-. 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S:�I •f p,T� _�— •��?"� � � ��U�� 0"T Q'�'(', pf5�etrC UY �(� �< J�� �j Y" 4( I/'e � ��r v1 �� �"{�• � �/ ,� � S�q C i � j"PSS�t�t' �l c(,� ; .� � Cv r-�- � �f� % � I r �!P � c� V' �f � �(�C> � �f �{� S . ��� �,�� ���.���� �---- -�-�- �c � �� �� I������„ �,�,. �:,�¢�;�_;,11 IE-���Il�IIs %� STTE PLAN Name C�"c`�'1'-U'�S. �' (� �Y� S Tas Ivlap .# JZ Pa-ce1 #�� Subdi io Section/Lot# /'v v � Authorized Srate Agent Date System romponenes represent apprnnximate conrou5 onlc: The caatractormust 9ag t6e system paor ro be�,�nning t6e insrallarioa ro i�sum r6arpropergrade is mamtamed. �.��.�� ]PI��.���� �--= � ������ ��rl�s I� . IE:sa-sa�� � �ean��.11. I�3L�.m.11,E➢a. wneT: '' vms Tax Map: ��Z Parcel #: � Date: z I�ine Tap Tap (Sch) Tap �'lo� Line �ength F1odv /�oot # Diameter(in) ( m) -:. (ft) 1 ��� � S. S mo < < l�sS' 2 �� 3 4 5 6 7 S 9 10 � �� � ft of line x 65 a1. per 100 ft=Z�O���"? ; 100 =�6 o gal 75°lo x26� ga1= /� � gal per dose 2f" ga1 per minute (gpm) = k'low I�ate �riction �ead Loss• � rl ft per 100 ft of supply line x`V Z� ft of supply.line = 100 =�• s ft .�� ft x 1.2 =�,_ ft of friction head Manifold Size: 3—�" Force Main Size: 2 " PVC Total Dynamic �iead =�ft of Elevadon head + ft of Pressure head + Z ft of Fricdon Head = 2Z TDH Pwnp Requirement: 7�`� GPM @�Z ft of Head Drawdown: 1 q�' gal per dose ; 21 gal per inch =_� inch dra.wdown per dose a� � :� �, a� , � �� �,� � � - ���� — �i =�y�����t0 — • � � � • r ■ . . . � ,. � �`1'i . . ��i�»�o�oo -�-o-o-�-�. o-�-o-�-o-o-a-�-o-�-o-o-�-�_�-�-�-,_o-.-�-o-r-o-,-. 1�1 �I 1�1 1�1 ����*��*�������i���s���a���.���� I �. . . _ !r!�!!!!�l���Nl�!!l��:��!!!!�:lf � � � � r. :i e a �: ::-v: �lllai�hv. Lwi/ma�o: 9m� � '�'s � • l�Yauifoid Six� I� Ta s il�iani%ld Ma�x No. Taps Qff one side gize ince b 3/s ior ta i r�oth �.c» +a.,c 3/." tans 1" � 3" y d" � �n K . . • 9 2i � � � � " �`low er Tap Size 1Llcuerial Flow G��t �4" Sclied 30 �•j �: " Sched 10 7.1 ;, '' :iched 80 1 � 1 =, " Sclte�i s0 1:.� Tax Map � � Parcel # � _��`S� ������ Subdivision _ � Phase/Sectoin/Lot # ' � (�' � � � � � # of Bedrooms �� I�xn�a���n�,r�cn.��a��.I1 ]L���.Il�ILa Operation 1'ermit Applicant: _( , v( R'V' �� �V Or r�' S Location: _ __ , . ,e ..,� A .� This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. System Type: (In Accordance with Table Va): _��� Product: �Z %'Cl0 c.cJ Initial: Repair: � Expansion. � o<< . . . _. . . . _.... . . �- ,��i REHS/REHSI � Licensed Contractor r� � _ �, �.� -r'��5 Scale lit1Z �, . s� v�)`" v . _. _ :..._ ._.__._. Date � �Y Date r�i ��ies l� t�el�r S ,� S � � r S� s' �` YO ,�/jc!/ty� �ji�,e �� I � �("'�- �� i�"'V� �r'� � .�-,,,.� �e �r�r s �� Line Len th 0 2 �� Q� i �v � Total 36a ' ��• � D 0 � � � Tax Map: 72 Parcel #: / -••Y- Septic Tank System Checklist (Type II-VI) System Type: ��� Se tic Tank InitiaUDate State ID& Date: �- z(�( p � 3 � � l�fZ Capacity: ��,a t/' Tee and filter �/' Baffle � Vent Riser � Outlet boot Perm. Marker Distribution - -- . _ �. __... . _= bX _ eVe._s _set .__ _ . - .. . _ __._ .. ... . _ Serial Pressure Manifold LPP Notes: Nitrification Lines InitiaUDate Trench Width: � ft. 3 l Trench Depth: ( Q, ft. L/ Total Length: �o ft. Minimum s acing: ft. Rock depth/ uality -- Damslstepdowns --- Grade (< .25" in 10') �/' Cover (6" minimum) �� Setbacks - From wells - -._ . Prc�p��t�� lines ---- _-- - --- Foundations/basements �' SurfaceWater � Other: Pump System Checklist Pum Tank InitiaUDate State ID& Date: j z�� 3j � � Capacity: � S (o c�� Riser (6" min.) NEMA 4X Box Model: Piggy back plug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of taps: �-{ Size and sch: Z« $ o Contracted Certified Operator (if applicable): L► ,q n Tank Com onents Init'aUDate Pum model: �.fe �-tr � SZ 3 1 Block (4") Nylon retrieval rope Float tree and attachments �/� On/Off float swing: in. f Ala��n float (6" separation) t/^ Anti-siphon hole Check valve Tlireaded union Gate valve I/' Conduit sealed Outlet sealed ` Approved and secured riser Su ly Line Size and material: z- in. `��5ch. Length: �- �Yo ft• Notes: �