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A35 63A,pc�l6cation Da#�: l�/Lll � Amoun4 �aid: /5C�• t� - �e���¢$'�: � �,�'idl> � �U � 4G � �-6-a� _ ���� .��. ���..��� - - - � � ���� �' :m�n.xc-�aa�---� �aa�mlL ���.m.11.�I�a �����C.`t�1Ti�� �{�� S���C.�� � ax ;�l�p �• I-( c� rJ ',�'ar�i �• � o � i� �iE INFd�RRflATI�R! 3N T�E v�P��9CFs'�OP! F�t� �iV 16lA�6aOa/E3�iENT PE'R�Iflll' �S i�C0i�4ilE�'i FALSiF�Ei� �1�9�9dG�� O0� T9-iE SiT� !S ,4�TEH�Ei) �i-9ES!! �E l�fi�'ROb'E3ltiE,�l�' F'4E�i1liBT.�ND �IdTN�I�tZd�'a��� 7'd� CONSTQaUCT SHALL, �E�OnAE INVA�.1�. . �,��s��A �`k.d �esse RLt � ��f�' 9) Per�vnii requ�ted b:(Owrnerlagen pros eciive c�wrae . C3� P�,cGrl`f' Home Phone: 7'��70.3 Address: l:'� �.c, v l Business Phone: �,?,L� ���-57�Ui �chr_no �]G c��.�?Lj 2) �aevo� and as9dr�s o� c�ra�nt owreae�: C r? . }� rn n K- �s`� �- 3) �raperty i�esc�g�i6on: Lot size: Township: i�I���,�,Subdivision: Directions to the property (!ncluding road names and numbers): (�� n�,t,r(' �.�I� G1Q�•�n i-%11_ ����„� c.lu.1�..5�,.,,l�.hc�,�.��. i-, r rn m-, /y' a I I'tfti ��i 'N e �n c ��„av Wi,;-t� � Lot # t�c•J 4) �ro�osed 4D�e an�i �ge�uc$ur� �es�riptaon: answer each of the following questions: a) Proposed � Existing T_ype�of Structure: _}�o�5e. Width:� Depth:� b) Number of Bedrooms: ��v Number of occupants or people to be served: � c) Basement Yes_, No ✓Will there be plumbing.in the basement? d) �arbage Disposal: Yes , No � � 5) �Bate� Suppiy T�pe; Private ✓(new _ or �xisting�, Public_, Community , Spring _ Are any welis on adjoining property? Yes No _ If yes, piease indicate approximate location on the P'a� •�sit pian. ce! Il Nt,�.,� t�k�.Q �'c�-�s�t,r�� Comrnun,� we.�.Q ? in P l�� 6) Daes yo�ar pa�oper�y ��ra�an p�vaoaasBy 3c9es�t6fsed juacsa�ictionai wet9and�? Yes_ i�o� Pl.�SE i�0�'� THE FOLLOliVING: . 9,a� P�T �� T�9E �ROP�3�iY OR SOTE FL4f� i�fll9Si BE SUBAflIi'TE� liVl'�4�9 THBS .9►PPL�C�'e�'9Q(�. 9 4�ROP��� L9iVES AP�D COaiNERS MUST �E CL�RLY MARKED... , � 9 T9�IE P�dOP�S�D L�C.4T1Oi� OF A►L� STRUCTURES 6ViUST BE ST.�4�� 01� �LAGGE�. � T9-iE �IT'� MUST �E �DILY .,�►C��SSi�L� �'t�R A�N EVALUA�'iON $'f 'i9-iE �l�►LTi-1 �3E��RT�iE�IT SiAFF. I hereby make applicatio� to the Person Caunty Health Department for a siie evaluation for the on-siie sewage dis{�osal system for the above-described properry. I agree that the cantents of this appiication are true and rzpresent the ma;cimum facilities to be place�i on the property. I understand ifi the site is altered or the. intended us� ct�ang�s, the permii shall oecame-tti�alid. ��� Cwner or L�Gi Represzntative ����� ��n�� Daie PCND, rev. 06/27/02 . _ . �..������ ���� �� � . . , • ' � � � ���� . . IE�..-�aa-o� � ea��.1L ' IE�Tom��]ta. , N e��� It�Z f q CT STTE PLAN Taa Map #� Patcei #� t ; Sub 'on Secrioa/Lot�# ' . � —� . . Authorized Stax Agmt Date . Sysrem compc�acats repirsear appra�te coaroura m1p. T3e caamcaormust9ag the aystrm pn'or m beg�ag the fasrsllatioa to 1, j msutr �atPi°Pergnde is mnrint7ined ; . � . �i . . { . .. . . ; � . A , . . ' 1 .� � � �� � � • �i . . .. . . � .cy�� �{ �. � ;:�j�M . . .._ � ' . _ � ' :i;' • . . _�.' _ ` ....�;1 . : +� --. .. ..... � � � . , , I . , : � . . � ' ,... �. _ ���AP���T",� � • � � � �/ � . .���,�.:��z.�� , c � �� ro�y , . .� .� � �Nf�f y a� �> K�X-ca.fx��, : �..•..+r � . � � : .Sc�� /3 i9Gr , � s , ';�:' � . 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Yp�Sc,�r-e � � • . � � � ��`5��� .��K���,,p � ... � • . , • . ' ,. , i . .I �`7"• �' W�'�� l .'�;� :S. . ��r���• . . � . ��ja�rM�� �, ��;`' �; , � � � " � . � - . i' � � � Co��n , �. ��"''�L ��' � ;;. + . ��. �z sc� �S� �v�s . , . . . , ;, . �� ��.Ks, �u� r �Yvs�� -�- -�i �� �5���� � � , s �� � �q � � �-X� s+' d�R' ✓�ti e �°� � � � G�,� �i�'{i�1 �d��'t.PS- ��� � �� SP'� v �„ , d�; �, t��s • , �r ch��� �� ,M;�• � ��t { Cc� - �.��� ,),� ���� �� ....^. ,•• , —�,_, � � � � � � I� ��-a� «� �.�. «� ��.�..Il I��-3L � �a.11 �I� T�x M�p : Pa�rcel # � Subdivi:sion Ph�se'Sect�ion Lot # Applicant: ��C�S�2 f�,�TZ���� V Loca i n: C� -�'I S Q e-�' �!' c�l.✓ -3i� � Improvement Permit Permit Valid for %� Five Years No Expiration Type of Facility: � Nla � 'G�P New � Addition Water Supply jAfl°�c # of Occupants �'Lt�1C� # of Bedrooms Projected Daily Flow � C� g.p.d. Proposed Wastewater.System: ' Type: Proposed Repair: P �P Type: Permit Conditions: Owner or Legal Authorized State Date: Z — — O � Date: ^ � The issuance of this pernut by the Health Deparhnent in does not guarantee the issuance of other pernuts. It is the responsibility of the applicandproperty owner to in sure 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 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 Rules for Sewa,ee Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. Authorization to Construct Wastewater System (Required for Building Permit) * 3ee site plan and additional attachments ( �i�� S� :vt 'Q�G� Proposed Wastewater System. S Gu Typ� Wastewater Flow ��Dg.p.d. New � Repair � Expansion _ p �j Soil LTAR: �' c"� g.p.d./ ft 2 Type of Facility: �D1��KL' S' � Basement _ Yes SC No Wastewater System Requirements Tank Size: Septic Tank: �O gal Pump Tank: � gal Grease Trap: gal Drainfield: Total Area: -eX • sq ft Total Length �X � ft Maaumum Trench Depth 'e%� • in Trench Width �?� � ft Minimum Soil Cover: �_ in Minimum Trench Separation: �C • ft Distribution: Distribution Box Serial Distribution k Pressure Manifold Specifications: �_S� 'l� ��-e��` Permit Exn. Date: ` j� The type of system permitted is � Conventional Accepted � Alternative. I accept the specifications of the permit.� Owner/Legal Representative: k �� Date: Z`�—� � PCHD rev. 11/10/OS ���, � IPI��.� �� ������ 1��� IE��� ^ e��.D. ]HL�.�.11�. wner. �� l Tax Map: Parcel #: � � Date: � � I�ine Tap Tap (Sch) Tap Flo�* Line I.ength Flow / foot # Aiamete in) ( m) � ;. ft) 1 � �fc� - �s' �v ' . p SS 2 �� S• � lv�� 3 Y � S• S • vv' 4 � S 6 7 8 9 10 � 7 �v ft of line x 65 per 100 ft= L Q S�o� �q�� ; 100 = 14' �gal 75% x� ga1= � S gal per dose o� � gal per minute (gpm) = I�'low Rate �'TICtIOI} �� N h I.osS: /• � ft per 100 ft of supply line x'V ��� ft of snpply. line ; 100 = 7 ft �—ft x 1.2 =�� ft of friction head �. Manifold Size: 3� " Force Main 5ize: � " PVC �f TotaI Dynamic Head ="' 3sft of Elevation head +�o� ft of Pressnre head + ` ft of Fricdon Head = ^' TDH Pump Require�nent: � GPM @`v �• ft of Head Arawdown: _ ��':S �al per dose : 21 gai per inch =.�_ inch drawdown per dose _.:� a i �, �,� ,r � ��. ,.� , , . - �.:�. _ ��;+�s����ts � ,..., , : : '�`" ' .,:,. � � �Ii�)l���i�0 - ..... .... .. ... �I� �� '� �� � •��+*��*�����ly���������!!�l��� 1 1 1 I �►��:a�����������������i1�������* � � � � � . - , •-. . _ , :� :� : : v: i» min Scl�e�ule 40 � 9mmra t�mt97erq 6 ' ' .. . . ' . .. .11 . � . .. ' . _ _ .. . . . . ' .. � . . ' �Z cIIA�[IriloIfJ'I'I�� @� : .: , ' • 1 . ; � . �: , : ti, , • , , ;• .' . , '. • ' , .:�. , :� � � ' • � r • . ' , • � . '. ... '�. � �� ' ��� a��SrE{• $���� ��• .• , . . ���a eti �.L at�� i��d : ti ,� � . . ti.:� �d ' ; �� '.'� �o �a-t�� � . : � � .�s.� . � d� �' ; ; � •. �'I�i°�� � �og uawpeeizQ� � ; • • � . �ieoid �[ooT:oded,� ) t ; `• , r � . AO �d -i�'I �H ` �' '� (Qaci�daS.9� ' • ' ; . i�*'I �[� rieht�'�H . .• ' >' �.9� �i adcr21 � 0"tah , �d addOtrH�S �L +��a pi ���o �J �°� P�i�°d ` • � �dd . �T.AtL PH1L�d �ad0 , �. . - ' �i� ''- . _ .• }AO:� 6}�i.11i0� �i@'[}IDd�"'�� .��� l; � � . ���5 u4 , . �y ca diZ $�� � • �, od�d �Ad Op H�S ��p � �'�°°� � �� �t�a '�z ���s ��.� �� �'[°H u°�i�S � �.bA p�.i �ucaad0 ' � ; ' , �Aza '� ' �', � ' '',� t � • '`• . .x : . . . s. � .. .,,. i I � . / � � . • • � : � � , . . � • � 'IiAO� LW��`j � . • fiA�. a� 1 � i ' ='' . —� i�aJ t��al'3 . uoi}r:edsS rZI �lYl PeiiS °.LP�d°[S , . � �oa��.�z.��a �t �.� � L � t�dI°�°� �'[�:S g� V'YtIIH � ���� � ���� �� ,y11,( � � �� � � � •� � � � ��.�-s.a-��n-��s�.��.� ��.���. Applicant � �5�- ��� � lQ Location: � � , t __, i � - _ .; � � ',�� ' .: �: � / � a�x Map I P�.rc�el . S�u�b cili v i�s,i o n Ph�se Sectio,n Lot � � af 6edu Qoms � System .Type (ln Acr.ordance Wifih Table Va): ��� THiS SYSTE3Vl H�+S BEFa� INSTALLED li�! COMPl.IANe� WtTH AP.PLICABLE . NORTH C�4ROL1RIA GEi�ERAL STATUTES, �RUtES EOR SEiIUAGE TREATMENi'. AND DISPOSAL, AND • ALL COPiDIT10iVS OF � THE lMPR�VEMEI�lT PERMIT Ai�D CONSTRUCTION AllTHORIZATION. - . . . - _ ��;��/� - . . uthorize Stat Agerrt � Date - � �n By: �� �-�,�:v'3 . o��:. � �� �� � . . / � �t/` c�i,1� �,n;,� 'e��f ' � � ' . �. . � \ : ��� � z` 1 9 �'�Z�a � � - ��- S l v-v� S � �'-�,Z . '�-13-Z�i� �' �?�S l �� . . ��" �5' l5 � �,,�;���� ��� � S��- �`7` Q�a.��n��f- ��'� laK� �� . h �� ��Z � S�� �.� � j's PCHQ, rev. 07/2Q/Q4 � ���� ��� ��5��'���� �:"�E��S� �'�� �� - � Tax Ma� #_y�"_��Parc�l # 3 Sys�em Type (Tabie Va) Owner/A�ip�icanf � � S�bdivision Address/L�ca�ion � SecfPhas� LDt # ' pc3�d rev. 3l13/01 Application Date• T 2q''-j / Amount Paid: . � Receipt #: Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building Addition $150.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ~�` Tax Map: � �� `?,�� ������ Parcel#: �Q — � � ���� � lE��a-omm � ���.Il ]E-���Il¢]� Services for Services Construction Aut6orization (Fee is dependent on the type of Permit Revision pair of Ex�sting Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information• Name: �'C'r� 2,C-,"�"z,�.�f'� , Address: �3 3��-�-�• h�:rj H o I I ar ���C � o�c ►� c3c�r� lUr. 2) Name and address of current owner (if different than applicant): Name: Address: 3) Property Description: Lot Size: Ot C. Subdivision: Address and/or directions to Property: ,, _ Phone (home): � - S q �j -3 � �3 (work/cell): �/3 y- 33 y- q 3 `t' Phone: Lot #: ❑ yes "�no Does the site contain any jurisdictional wetlands? �s ❑ no Does the site contain any existing wastewater systems7 ❑ yes �io Is any wastewater going to be generated on the site other than domestic sewage? 0 yes 'T�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? ���( C��� ���c,6ti (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ��� d"� S�c7'� • ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: .�Repair to Malfunctioning System Will there be a basement? � yes ❑ no With plumbing fixtures? � yes ❑ no � ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: 5) Water Supply: ❑ New well �Existing Well ❑ Community Well ❑ Public Water � Spring Are there any ex�sting wells, springs, or existing waterlines on this property? ❑ yes ❑ no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): � ❑ Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other pny I certify that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subse�rr ly altered, or the intended use changes, all permits and approvals shall be invalid. $i'gnature (Owner/ * Supporting docume ve*) yz9/S ate 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. (1(1/11� PPrcnn C'nnnt��Fnvirnnmantal T-Taaltl� Z75 C A/Tnrrt�n Qt C,,;tol� n.,_.L_.._ wri,.,•,�.,� ...... _.._ .___. ����,s� ���.��� ���.��� ?.Lo �ra-Yn �z- � �ra :r�n � �n.-��.IL IF—� � �.11 �I�n Taz Map: 3� Parcel: � � Subdivision Phase/Section/Lot # �j �� t t f' %�� A . ,. � Improvement Permii Permit Valid for: Five Years ___ Non-expirina Type of Facility: New _ Addition _ Number of Bedrooms / Occupants / Employees / Seats: Proposed Wastewater System: Proposed Repair: , - Permit Gonditions: Authorized State Agent: (X) Owncr or Legal Representative: Vt�'ater Supply: Projected Daily Flow: gallons/day Type: Type: Date: The issuan�e of this permit by the HealLh Department does not guazantee the issuance of other required permits. lt is the responsibility of the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This improvement Perc►iit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeni is noc affected by a change in ownership of the property. This permit was issued in c�mpliance with the provisions of the North Carolina �Luws and Rules for Sef�ag� Trealment and Dis�osal Svstems'(15A I�TCAC 18A .19U0). Neither Person County nor the Environmental Flealth Specialist iv�rrants that :he septic systcm rvill c�ntinue to fanciion satisfa�torily in the future, or ihat t�e water supply wiil remain poia�]e. Authorization to Construct VVaste�water �ystem See site plan and additional attachments (_). x Proposed Wastewate.r System: �(,� yVt,p �pL(,tl�w �i e�r (*)Type � Design Flow 2��_ gal./day New Repair� Expansion _ Soil L'Cf1R: �� gal./day/ft2 Type of Facilir�: ��12 S Bssement: _ Yes � No (*) System 7'yp�s Illb, lilbg, IY, and V; require perioclic system inspections by the Ferson County Health Department. Wastewater System Requirements Tank Size: S�ptic Tank ��� gal. Drainfield: Total Area �''' r4 �� sq. ft. Trench Width�� `�ft� Pump Tank � gal � 'fotai Length a'x � �ft. i1�i►�.Soil Cuver� in. Distribuiion: Distribution Box / Serial Dish•i s �- �uthoriz.,d atate Grease Trap _ gal. Max. Trench Dzpth2`� 3�n. Min.Trench Separalion n / �t ft. Z— / Pressure Manifoid � .� ' "' �'� � P� �� _�1u��� �/�f2s � J-c,�e�e c' s� l��x 1� o- �re ■�■ �aoa s � tssue Date: �! $ Permit Bxpiration Date: S—� rZ� T'he system permitted is: Conventional �/Accepted / Alternative ( Innovative . I accept the cotiditions and specifcations of this permit. (X) Owner or Legal Representative: Date: Person County Environmental Health, 32� S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) •s o � � x � �� �_ x �n �- � � ,� � a � o � _ � S , "_ � � � � � => � __--- ---- � -� ��:::y� �` � , .:.a;.:.:., , �. �. . _ .�-::� � � �� �� � � '� . .� �� � -- s� � � � N �� � ;�- � �. . � � �'� ... ..� (�. � �'� � � R:<!�:::.; ;5ti �..;✓' . � �. , � ~�`� �� �c . .,��� : : � : ��` �:,��. � �' � ��` � ��.�� � � �n � � � � x ��� �� G• y ��� � �� � � �. w� . � �. �� � b � � � - � � �� � ��� � 6; � � � � � � � ,p' �+6. � �� � � � �: � � � , � rt � �4 1� � . � rG �_� ?` ) � ���� �� ^r--�=.r- �' CC�° (� �f T �i'Tf � Tag Map: �5 Parcel:� Subdivision Phase/Section/Lot # Valid for: Five Years Type of Fac� ' Number of: Bedrooms / Occupants Proposed Wastewater System: Proposed Repair: Permit Conditions: Autherized State Agent: �_ (X) Owner or Legal Representative: Irnprovement Permit Non-expiring New Addition _ V�'ater Supply: / Empioyees / Seats: Projected J t� gallons/day Type: Type: Date: The issuan�e of this permit by the HealLh Department does not guazantee the issuance c�f other required permits. It is the responsibility of the applic�ndproperty 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 ImQrovement is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the NoMh Carolina `Luws ��rd Rules for S`e►va�� Treatment and Disnosal Svstems'(15A NCAC l8A .19(i(1). Neither Person County nor the Environmental Health Specialist ivarrants that :he segtic system will cantinue to fanciiaR satisfactorily in the future, or ihat t�e water supply wiil remair potable. Authorization to Construct Waste�vater System See site plan and additional attaehn:ents �_). il Proposed Wastewater ystem: � d�X —�� �(*)Type �� Design Ftow 2�{a _ gal./day New Repair � Expansion _ Soil L'ff�R: � 3� gal./day/ft� Type of Facilit-�: 2��� S- Bsser�ent: _ Yes I`'o (*) System� i'ya Illb, Illbg, IY, and i�, require periodic system inspections by rh.e Person Counly Health Department. Wastewater System Requirements Tank �ize: Septic Tank �_ gal. Pump Tank ��_ gal. Grease Trap gal. Drainfield: Totai Area '�� ' sq. ft. "fotal Length � 0_ ft. Max. Trench Depth ZY-3{qn, Trench Width � ft. Miii.Soil Cuver i� in. Min.Trench Separation � ft. Distribution: Distribution Box / Serial Distribution / Pressure Manifold � r -2 ' ,S`� �� �t PS Specifications: 5��� j� ��- R ' � � r x ?0 � �t � Sei i �a S�s�A �i i.[e -���'4 �Pr�, rcL� �P•'z • �` V0� S l -PX � ✓�� — c��►� e -t- • K Authoriz:,d 'tate Agent: � Issue Date: �'�2�(' (�p Permit Expiration Date: �-2�— 2 ( T'he system permitted is: Conventional /Accepted �/ Alterna ' e / Innovative . I accept the co�zditions and specifications of this permit. (X) Owner or Legal Representative: __�,__ Date: � C � Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC27573/ph: 336-597-1790 (rev 5/12) � � d S1 1 � I � � I � � � � � � , � � ..� i �, • z�-.`as r, �� � xT , `^ " �� � r� � , , � � __ _ . — S . � � r , . � j � ^ � .,� �",'' ` _ � . � � � ' � r� ✓I + � a�1 `1)f Gj._�1�(�j:,. � ,U �' � �'�1 ,..��, . � � 1 �. .. . � � . . 1 �_ 1 �, it .' . • � � .�:� , � / _ �_ ' . Si� `�! r r E�y �' - n ^� �0' � � �-- =`..rc �� •� ,� S, V1 � . , _1 �•.�.v, �_ � '���.� •�•. � ' v � ' � �� � , ,�. 1 tn � ) �, F1' � �1 �� 1� � —.� � � � , , i � n� � / � � �/� I � i �p� f - � `� .`t '� (�.. . V T , lu:' i o "' a'. 5` F�D - �. � =�' — i ;�� �. � ���� �"�� ��� ,) �' � � _�. '�j � �� � � , • + .� � � -�,, • � � � ,� f � � � R:<. : �;: � .;.r . � s '� � W _ , - ��= -'�: . "� � � , •�'qjt�` •� .� � �, \n � 1 � � .i: ..�:$. . � .. , „j Y.� ^ ' ' o '� � + �J J � � V]� � • �: c\ � _ ' J � . o 'C� � ' g'� ' �`:.. � _ S � . " „ � � ������ ��� - �- � �. , y n��: ' �--� x -`. � � � H �i�,` ��� � � r�--' - x,,,_�f[ 32_� ft K '� f .. � l��� \ � � o' � � � � � .s ' t ''b --� � '� � �'�� � � ,y � � � � � � U� . � . � ' • i � � �� °p � b �l'+ ?,�� . � �, `" a ` � � � � � � '� � �Yfl . , � ` � � � . . � ._ p + � � „/} � � � "�► � � j -.� � d �• � �n °' ' , .. ri - � 4� o , V:' �;ti • ' �^ .!' ' �, _ ' � N� �R ; � � � � I`' ',a � � � � � � � �. �rl _ . ' � �� ,�`. �' . � �' �N� s� .�s � -;- S S � o � �� � .�, � s�. T�' �, � �� �� w S T'� ���� t� � �� � ��`�. � IPI�I�.� ��� - � � �.T�T'IC�`Y � A �.. IE;�.�� ^��¢�.11. IHI�1. r1L,�]�. � �"� f� I Owner: Tax Map: 3 Parcel #: � 3 Date: S—� IS �,ine Tap 'Tap (Sc�a) 'Tap �'lopv Line �,�ngth �'lodv / f�ot # DiaYneter(ax�) ( m) �'. (ft) 1 3 �fo z. S o-a � . �z B 3 �lo � l2, � 2 3 4 5 6 2 �� 7 8 9 10 ft of line x 65 gal. per 100 ft=� : 100 = gal 75°Io x gal = gal per aiose gal per minute (gpm) _�ow ate �'riction d Loss: 00 ft of supply line x supply. line = 100 = ft ft x 1.� __ ft of fricf ead Manifold Size: " rce M ' e: � " PVC �otal Dynamic �$ead — ft of Elevadon he _ft of Pr.essure head + ft of Friction Head = TDH cement: GPM @ • ft of Head �al per dose : 21 gal per inch = inch drawdo er dose ��� :�.� a:� :� � ,�:,,�� — , � hY � '�\ �����t0 �_ . . , � : . . , , ,. 1 ,: ,. � _.. , . �It����0�00 -�-o-,-�-�. ,-� o-�->-,-,-�-,-�-,-,-�-<_�-o-�-<->-�-�-,-,-o-..-. �� �� �� ��� , ��i,�l���i�����i����f���i������� � .... :... .. ... ���+����r����Nl������i��i����� 1 1 I i � � :.� .,._ . ;, : : : Y: '''' � .��-. . sa � l�ianifoid Siz� I � Tap� — Niax �To. Taps off one side l:tednce bv'1a ioP t2Dq�'��� � 4 5 � 3 dU+ ( 2i � 1Z � � Fiotiv 1 er Tap Size illcuerial FTow GPY! ?: " Sched 30 �•� �4 " Sc3ied 10 �-� ;, �• �claed 80 10,1 ,, .. Scited 40 := ? -� �� �. ���� �� �"'1 ...,_ � _ . __ �. ,+.: :; , � � ���� ,. .����..v�s�sa�ca�n a��rn.�.�.IL : IE-��,�:?L�I�n . WELL PERMIT PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT -- Tax Map � �7� Applicant: Subdivision: Location: # �93 � �;�Tovwnslup: ��Z �t Lot # .��pe ater Supply: � Individual _ Community Public ,w'� �,` ✓ - �` w �`' �� - g�� � R uirements: � �� � � �` 0 e;� � - 'L ite Approved By:� f� = 3�-��;lo.._ Lmer: �A� Groutin A roved B >�+� �� �k� �"� �'# ,. � � las� �stalled b g PP Y: .�_-, ' . � ___—�.Q� Y� - Well Log: aS7 Depth set: _ Pump Tag: Grouted: Well Tag: Date: Air Vent: Hose Bib: - Water Sample: Casing Height: Concrete Slab: Well Driller: k-� n�`$�(� �,�5-E'�� �t�0 ���v.,,� Well Approved by: Date: D z � ****See Attached Site Sketch**** Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. PCHD rev O1/27/04 � � flo � 2 `� y`� ���* : 74�f ���� �� : � � l� n �-.� - _ a a � _�4►�ne%t-� I,✓�l ( (�/' � _� � � ����; . ��.�����.,.�,-,. ��.��� � ���.�.�.� D� D�SI .�-� - O U .-- ;� Grout Log Owner: ����7t/ 'cC�� I u� Tax Map ��� Parcel # C� Location: �1��(nC� r�:I( �2�. 7 Ns�ssc) �/�c.�Fo�.K� �7 1�,a�Ctie� Nol�n�,.� 7 G�- P�`-�- Subdivision: Lot # • Well Constraction Distance From nearest Property Line (Minimutn 10 feet) r� Distance from Septic System (Minunum 60 feet) Total Depth: 2 p�' ft Yield: �_ GPM � Static Water LeveL• �_ ft Water Bearing Zones: Depth i On ft!H� ft ft ft Casing: � C �/� Depth: From .� to � ft. Diameter. � � in Type: Galvanized Steel � Weigh� Thiclrness: � R�. Height above Ground: ;��_ in Drive Shoe: - Yes No Any problems encountered while setting casing? Yes �No If "yes" give reason: Grout: � Neat: Sand/Cement Concrete GraveUCement -. Annulaz Space Width � inches Water in Annul Space Yes No �Method of Grou� Pumped Pressure Poured � Depth to Ft Materials Used: No.�Bags Portland cement � Weight of 1 Bag � Pounds If mixture (sand, gravel, cuttings) - Ratio to-�-- ID plates: ✓ Yes _ No 4 x 4 slab ✓ Yes _ No Liner: - .v Depth: Date Installed: Grout: Installed by: _ Drilling Log Location Drawing From To Formation r � P� � P I,� G � 0 iA ��� �� 'g„1-�„� _ N�s�f a� o - i� �� ° � . r��yh� . . �7 ,�''' �, I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth by the Person County Health Deparjx�y�x% _,� _ � Signature of Contractor ID#��/ y� Date c�- 30 �C Pump Installment Pump Installation Contractor. �(,�r(►e��C— ���� v�< <� •��P State Registrarion Number. 3��� � Pump Depth: G C� ft Static Water Level: 2� ft Pump Make & Model: �� Sc,G'�'e �- Pump Size and Rating: �%Z hp 1� gpm I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect on this date and that a copy of this record has been provided to the well owner. . Pump Installer Signature� �` Date: ����� 6 PG"��iD rev O1/27/04 PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT q-ZR-tI 9-�5-U�e �], ..o' 0�.3 Date of Inspection System Installation Date Type Tax Map Parcel # 133 ���r �IIoW t�h, Property Address Instructions: Check yes or no for appropriate items and explain in space provided for 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 carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted ? Septic tank needs pumping ? Inches of solids: Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps present & functional ? 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): Elapsed time readings ? Counter readings ? Drawdown rate: YES / NO ❑ � ❑ ❑ � � ❑ i � �An� ❑ � ❑ ❑ � ❑ ❑ � ❑ ❑ � ❑ �� ❑ ❑ � ❑ DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?❑� Surface water effectively diverted ? Q Diversions/swales properly maintained ? ❑/ Vegetative cover maintained ? �,.,_/ Protected from tra�c/unauthorized uses ? � Distribution devices in good condition ? � Field free of settled or low areas ? � Lld °a,��� ❑ ❑ ❑ i �K i ��1�/_\:7:(.y I�10�" �i PRESSURE DISTRIBUTION SYSTEM: Turnups/cleanouts/valves/taps intact & accessible ? �j / ❑ Pressure head properly adjusted ? []" / ❑ COMPLIANCE: Compliant ❑,_,( Non-compliant Ll(J PuWIQ i"A n K�' i ser c ov e✓e� Needs Maintenance ❑ � aTli �iTi��ivAT. f'nl�flViF.NT1� QCCeSSr�1� aCc�.SSt��� EHS TS1.�171-�'� � � � ,� � � � " � �. �. � � � � � � �- ,�, a � S ' � ��� � � � � � � � ,�, -� �, � � � -�.. �. �� � �° � � � � � � �- � � �. � � � � � � �' _ �.. � � � _ � �-- , � s s � � � r�- �-- � �,�. c \ � -k-- ���"" � � �. -�- '� � -�— �-' `� , � �' � .��= �.. � �, � � � ry