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A40 244
Application Date: �-4-07 � � � Tax Map: Amount Paid: o20Q .00� Parcel #: Receipt#: 31b i 3 O ��� g g 1 � �.��� �.� �11.a�� �� ' r=—_r— c� � 1�J ��T`7��� 7EE�. :-�-ti-�� ��: .��..,.-�..,�-,�..�.�,.,�-�..�.�.71 3�1L 4�.�Rll: �.11T. . Application fo� Se�ices � (Sentic Svstems and Wellsl Servic�s �Improvement Permit (Site Evaluation) $200.00/$300.�0 (if> 600 gpd) C 1VIobile Home Replacement or Building Addition $150.00 (if site visit required) � ❑ Well Permit (New/Iteplacement) $225.00/$125.00 G Construction Authorization (Fee is dependent on the type of sys ❑ Permit Revision $75.00 ❑ Itepair of Existing Septic System No Char�e Important: If the infor�nation in the application for arre Irnprovement Permit is ificorrect, fulsified, or the si[e is altered, t/ee�t t/1e Improvement Permit and the Authorization to Construct shall became invalid 1) Services Re ues d by:,� Name: f�[ � ` �i�tcfS Address: '1'Z,� t-� i ( s ' � l'. � ls N��- Z7S�/ Phone # home): � � � Z,3�� (work/ e I -r't/ [ -Zl.! = �(Z B)Name and add�-ess of current owner (if dif%rent than applicant): Name: Address: 3) Property Description: Lot Size: � Subdivision: Lot #: Address and/or directions. to Property: l�l( y Z /�c��Q�c� �( i(�s <2c.P. �r,o .2 ff. s ,6E�•Ez-�, y��3'2 ff2c ��Q .�w�11 d,,�c1 l��w �?�1�� 4) k'roposed gJse an Type of Structure: Residential Business/Type: Other Number of bedrooms .3 � Number of people served�(seats/employees):� Basement: Yes No (wit}�-plumbing: Yes � No _� Garbage disposal: Yes No °� . 5) Water Supply�; � . Private Well '� (Proposed Existing _� Community Well: Public Water Syste�" Are there on the adjoining properties? No v Yes (please show location on site plan) I�ote: A cvmpleted application must also include: ➢ A plat/site plan of �he property that shaws property dimension� and tl:e �ize and docation of all proposed structures. ➢ A signed copy of the `Lot Preparaiion' form ver�ing that the property is ready to be evaluaterl. I am subenitting ti�is application to request services ipom t�ae Person County I�ealth I�epartffient. The infop�nation provided is �ceur�te. � understand that if any site is altered or the intendecd use changes, all perynits shall beco�e invalid. � n Signa�ure (Owner/Legal Representative): Da�� : C,� Df� O� 06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-] 790) � ���� `��i ����� �� �� � � � �-�.L�! �� ' q rs�-n.s<o-+^+ �-TM,+ <e�a�.��. �"���.li.�.�.v. �fx M a � � • ' a rc�e • Su:�.d;ivis�ian F'has�e S�cGian:Lat :. Apolican� M� c4ro e 1(..aw s . Location: �urdle i�.i� 1�s !�d � l�-F- ��►�e�� -f�, 5/ I`r��, l-h.,�r�ll� �'t'1� I Is 2d ���t �a�id fo� ✓�ive �� i _ Type �of Facility: # of Oc�ants lo_m ,�� # of Be� Froposed Wastewater System:�, Propose� Repair:� �'nr �Tna�roveaneat ��nmit ' � _ I�a �iiration i1�., c�wel�� v� _ New ./ Addition �a#e� �nppiq i vQ;e wel/ ro �_ Pioje� Daily Flow 3( on g.p.d. . mn �� C�v�n-h'or�ll � Type: b ,��Prrfi��no. 0 � � Type•—� b ' � .. . . . . . � �► : � a. �� Uwner or Legal Represeatative Sigua#ure: Date: Authorize3 State �Ageut: �-t��, ,,, ,� � t��-� Date. ci �-�l I�S'1 The issuance of tlris pe�it by the Health Dzpa�ent in does not guaraatee the icanane� af other pe�is. It is the responsibility of the � aPP��P�P�Y owner to in su=e tha# all Ferson Coimty Plaanmg and Zrnung aad Buiid'mg T.nspectiaas requiremeats are me� �'his Improvesne� �ermit i� su�ject to revoca�on if the site plan, pl�t ar the inteaded use c3�aatges. The Ymprovement �ermit is not affestesl bq a ci�nge in ownership of the progerty. This perutit was issned in cflmpliancE.�vith the provisions of the rTorth Carolina `Zaws a�d 3tules for Sewage Treut�nent and ]Disvasal Svstems' (15A. NCAC 18A .1900). Neither Pex�soa �Connty nor th� En�ironu�ental �eaitii Speei�list' wax�ranis Wat the septic tank system w�11 cmntiasue ta fnnetion. satisfactun7y ia #hs fudmre or'that the water supQly w�11 remain�potable. - .. . . . Aa�tlaorizataon �o Constr�ci �aste�vate� SYste,�m (Res�narexl f�� ��ding Pex�nuit) � * Ses site plan and additional attachments� i✓ )- - Praposeci Wastewater System:��trrn �l�r�sii ��m Q� Type��, Wastewater Flow �s� -g-p•d. New ✓ Repair Expausion�_, � � Soil LTAR . 3� g.p.d1$ 2� . Type of Fac�7iiy: S�n��� .��,1�, �.. 1.�;� g1� Basement _ Yes No � � , �ast+e�a#e� Systean R�wiremen#� � �ank Size: Se�tic �an�s: 1�u� g� �p Taad�: , l ck� gai �Grease Trap: -- gal �rain�eld: 'Tot�l Aa�ea: 1» sq f� -Totai Leng#h �/t» �t � 1lSazamum� Tr�nch ITe�th �� . aa Tre�.ccini Widt�t �_, ft 1��'in�u�a Soil Cover: �D .. in 1Vi'wiffimm Treuc�h Separation: / ft �istribation: ���iribn#ion �aa Serial �istn'i��aon � Press�se Manifold . Sneci�ca�nnss -�r,►I ��� �i� D/�1�� � DiAmD 1'�'2S5(.�►"P rYtQr�i �,1� �-�a� ,�:���rr�rl�� ,�.� G� ���� Anthorizes� State Ag��t � Permit Expiration Date: The type of system permitied is �'�anveationa3. P�� � i3w�eyrl���1 ����ese�i:ative: Date: `�/�10�7 Ac��te3 Alternative. I ac�rpt the specifications of the Date; pG'�ID rev.11110/OS ��� ?, �� 1!. ��� �� . ~ "- �` � ��� 1� �aavasa9TM�+�-TM^.caa��.� ���,m�.��ia. STTE PLAN Name }�h if�l--rn fi � �.�c Tax Map #� Pazcel #�� � division _ Section/Lqt#_ m i e �.1�-i 51 Authorized State Agent Date Sysrem rnmponeats represent appm�mate canmurs on1y. T3e conmraarmnstflag the system pdor ta begiaaing tfieinstallarion m insure that pmpergrade is maintained � �?�x(�t , - - --------�-- - ._ . l�1 �' �! , U � L � I ' �(1I � ' - z' > � . z , ,, <.� �_ - �,,;; z ;� , a�3„"'"�._-.-- i l" > �, :l ( . .i k ' • i` .. [ ,f .: P � � �; � . . � f �.� 74 .� ) .: y �� . � Y t } .'S R . � � f lY � ' �� . C\' -. ': iF �"' � 4? aY S; S: : ` � � . ;. �. , r: � '. r , �, x - �.� c n��. r �. {, 'i�.: _..------,'-- . _. ._._ _ f.__.._ _ �:... �: - . .._ .. __ . . . _, ,. ' ( , y, _ - - ..." L— ; � 25i 2 I W � e� . V � , C, Z� eo' �i s �° � F N :F �� N, e � : ti; � < , � �L �D ' N .. � _ ..—�. SC�9...� - 1''. `�1� � ���\d��g � r�e l� �"�==- :; 3� 1, �� u S _ � ��� ` � Q..� �'`i- �Q �rs. � lo..�� � �n�Q � '�r\��,� �� � �o �� ,` �� � ��� � r� �.� a-,d � �-j �S � �`� ��.es-{-��S _ �+�- Cr nV� �-���-h . � 5��- I7gC� i�, � � R..��-,P CcnVer�ii �,�Q � � ; ":�a:::�'}: / � ' � ,... n., ��`�.�� I����' .��� - ������ ���-�mm-� ���.�t ��.�.!�,� Owner. �.1i�har�l �Q�.�S Tax Map: �-14� Parcei #: �-1� Date: � la4 �,� �,ane ��� ia�p (a�c�a) ��p �Iow �e ��� �ow I �vot # �i�et�r(�) . { m) -. {if�) � � ,I . u� _. 1, I I � ' �2 �lv �• �7, 3 ' � °�! , �� 4 �12 �( � . "7, 1 5 6 7 . 8 9 � 10 � � <Ic� ft of Iine x 65 per 100 ft=�o"loc�o� �� : 100 =�. gal 75% x. l �n gal = I� g�i p�er �ose �c� gai Per minute (gpm) _�ow �t� '�'riction �ead � �,�ss: • 7 ft per 100 ft of supply line x� ft of snpply. line =100 =`i ,'� ft• u.`c ft x 1.2 = �_ ft of friction head �. . I�Ianifold Size: 3 t/ �„ �+'arc� il�iain Size: a " PVC �otaI Dyna�nic �ead =.��,ft of IIevation head +�_ft of Pressnre head +��ft of Friction Head = �� TDH �np �ieqnaa�e�t: ,��c7 GP1bI @ a8 • ft of Head B�rawdown: 195 gai per dose � 21 gai per inch =� inci� drawdown per dose :.,, :.� :�. :.:� �:�. : � � , ,�:� :.,:, �, ,. � -- a � �; - �t�t�����rs � 1� ., , : . ., ,. �,: , . ��c��omoo ,. QI 1�1 �) ��/ _ iiia*�i�iiiii�ii�iis�iirsiii�i�i :.._. :... .. ... �+�aa.���a�.��w�a`�������+a��� � � � � � � - �:, � _ : � : : � : r.�v►a.�w Ld/ao� I�O� !�Z �0. `�9� U$ 06� Sit�B 5'lZ8 ��C= �Y �2 i02' �W=� �O'�1: �» � � �`s" T317g 7r- i.a�a► g� a� .a M �'.ti '. '7�� d � �7C � . .,-�.,r. ,� 3" 9 9 3 � .�.-� '� . �b 15 9 � 9 ma� � S . m dii-r 2 i 1: . .. . _ � "Flowpar'Tap ��y :Lliuerial �Tm.+� G�� -, '• Sclieti 30 �.� :' Jcned =0 I "' 4 ; ' Jci:�BO ItO.! � =� � � �ciieri 10 � �= , F_.. . �. :.•���;�>:�..:;�. :.� :.�,. `���.:;.�..l:�c: .��- •`:���.� : . . ... ... �� ���['('' •.�^ �y':'.'.-::,• .. : �\ ' ;�:�.�.•�• ��r\,\\�� \.�'7 . ...,�a�: V'��•". ��. . �.a�:���:"�ii��'�,,�rl�%.��:�.9�i:Y'•�.�'�Gl; '}���lL��. ��� ���� � ��E�� ��+ E AT�A��� P�T ��DR V�I,I, ,SI� �,�.'��LT�' Tax Map �� Parcel # �u Township: Applicant: �v;�(�h o 1 �, .�zS Subdivision• Lot # Location:�rr11� IJ���\1� 2c� -�- l� c�� � i�-��r� u l�. ��� A.1 �'I/S �yp� �����e�' ��pp�y: � Individual �equna�ement�: Site Approved By: Grauting Approved By: Well Log: � Pump Tag; Well Tag: Air Vent: � Hose Bib: Casing Height: Concrete Slab: � Well Driller: Well Approvec� by: �**�See �ttac3aed Sate Skeich**�� Community public Liner: �Installed by: Depth set: _ Grouted: I)ate; Watea� Sample: ��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 foundat�on. Other conditions: Date:. PCT� rev 01!27/0� `+���4,/ � �11LJ �� �1�. V �.,. � ,...�,,, � � � � � � �ga.vrn �r � �rn,.-,.-,. � �n �.tn.�. �"� � �.Il.1L-�n. Sloped To Shed Water 5" Cover• ' .. Inlet From Septic Tanlc 4" SCH 40 PVC Pipe NEMA 4X Simplex Contml Panel � I—1 4" X 4" Pressuie Treated Post j 12" Separation Electrical Cox�duit — _ I • , Acce s Cover• •• , ' . ;M � 1 ? . ,. _ „ . , � ' ' � = � ; .'`�. '` . ; �,, Opening Filled With �nti Siphon Ho1a � Poztlaxd Cexnent Gzrnit (DoKzt Hill) Check , Valve High Watex Alarm Level � (6" SeparatiAn� � High Level - P1imp On -�� ' �� �VaporLock .. �. • Hole , . � Drawdawn �Up Hill) � . Law Level -Pump Ofi -�--"� . � . �• Precast Concrete Tank � � ;.; MatexiaiStrength>3500 � ` �'�.• •, • j ' ' - r Tax M��� � P�,rce.l #t �s` Suhclivision Fh���s�e'Sect;ion Lot # Duct SealBoth Ends Of The Conduit -- 24" Mininuun r ; , �.--�-�.. Threaded Gate Valve ; — -_ � Zip Co Tiet Nylon Rope 4" Concrete Block . ,- :�' . � . . � '� , Coxucrete Riser S" Separation '�,r.lPortland Concrete Gmut Mutu • - ' , s. � Opening Filled With Supply � ' portlaxud Cement Crrout Line •• Outlet To D'utnbutiox 2". SCH+IOPVC Pipa Float Wires .' � . ;� � F7aat� . , �Removable '. •' F1oat T:ee , , .' r � .�. . �, i •_.,, Joc�r, GALLt7N PIJZVIP TAIYK 9