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Applicant: �
Address/Location:
Improvement Permit
Permit Valid for: Five Years c� Non-expiring
Type of Facility:� P �,,,�Ty.��i (��tc� New �-Addition
Number of: Bedrooms►� / Occ pantd s�/ Employees / Seats:
Proposed Wastewater System: �o u
Proposed Repair: (icv",�,��, ' �� � p�,e
Permit Conditions:
Authorized State Agent: M; K� CQ s
(X) Owner or Legal Representative:
Tax Map: �� Parcel• -!
$;1�?�1VISi0n � K � �
Phase/Section/Lot # SO
Water Supply: __l,.,J� ( j
Projected Daily Flow: 3(�0 gallons/day
Type: �_
Type: �
Date: 12 - I!
Date: l j 2
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. Tliis
Improvement Permit is su6ject to revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in ownership of the property. This permit was issued in compliance with t6e provisions of the North Carolina °Laws
a�rrl Rules for Sewape Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmeatal
Health Specialist warrants that the septic system will cantinue to function satisfactorily in the future, or that the water sapply zvill
remain potable.
Authorization to Construct Wastewater System
See site plan'and additional attachments (�.
Proposed astewater System: r'6ru1e�,�,,,,2� t�� ptt,M,p (*)Type 7i" Design Flow 3ioo gal./day
New � Repair Ex ansion Soil LTAR: r j gal./day/ft2
Type of Faci(ity: `�� � ` Basement: _ Yes _ No
�
(*) Systefn Types Illb, Illbg, IV, and V, reguireperiodic system inspections by the Person Counry Health Department.
Wastewater System Requirements
Tank Size: Septic Tank d DD gal. Purr�p Tank �� Do6 gal. Grease Trap�-- gal.
Drainfield: Total Ar�a /� sq. ft. Total Length �oo ft. Max. Trench Depth 2y in,
o��•
Trench Width ,� ft. Min.Soil Cover ( in. Min.Trench Separation � ft.
Distribation: Distribution Box / Serial Distribution / Pressure Manifold ✓
Specifications:
Authorized State Agent: /�1 � Ke C.asl� Issue Date: � Z-1 [- 0�I
� Permit Expiration Date: �- I- 20 [5 g I �e�
� �u
The system permitted is: Conventional /Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit. ,
(X) Owner or Legal RepresentaNve: 1 Date: / 2, r
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Name � ✓�'� • � , Tax Ma � � Parcel # 3?0
Subdivision � ' Sectio I.ot# �d
��- %/— '�_
Authorized State Agent Date
System componenta represent approxlmate wnmurs only. Thc cotiuncmr must �ag the system prior to beginning the inst;adon m
inaure that pmpergradels ma�nrained. .
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Tax Map: i" u� Parce] #: 3`i � Da
1L��e �'ap �ap (Scb) Tap &'�ow Lirae �ength �'1ow / foo�
# Diamete�(in) { rn) .. (f�)
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�f Bd it of line x 65 gal. er 100 ft = ; 100 =� gal
75 °Io x ga1= � gal per dose �_ gal per minute (gpm) = b'low Rate
�'riction �ead
�oss:��_ft per 100 ft of supply line x"'�� ft of supply.Iine =100 = �•'i ft
ft x 1.2 =� ft of friction head
19�IanifoDd 5ize: �`�{ " Force Niain �ize: 2-- " PVC
�otal Dynamac lE�ead =.1� ft of Elevation head +� ft of Pressure head + Z ft of
Friction Head = _j,�_TDH
��mp Requirement: 3l� GPM @ I(a • ft of He d
Dra�down: �al per dose = 21 gal per inch =� inc$ drawdown per dose
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anifold lY[aa No. TaQs off oue side
Size (�ednce b'/: for ta pin both sides)
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SITE PLAN
Name � ✓1� • � � Tax Ma � Parcel # �?a
Subdivision � ,' c� - y Sectio�Lot# �v
/�- �— �
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Authotized State Agent Date
System components represent appcoximate contours only. The coritractor mnst flag the system prior to beginning the inst�ation to
insure thatpmpergradeismainrained. _
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Applicant:
Location:
C
Tax Map Ayo Parcel # 3�0
Subdivision OQKf:�sa c�c
Phase/Section/Lot # 80
# of Bedrooms 3
� Operation Permit
System Type (From Table Va): 1
Type V& VI Expiration Date:
�f- � 2 �1,� ��
Product (IIIg): Z n-F
Type V& VI Renewal Date: �1/,�
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.
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PC}
l� ar�o L .
2• 2t-(8
(Date)
2-28=18
(Date)
Line � Length
1
Z o2
oZ
Total O2
Tax Map: �+{0 Parcel #: 10
Septic Tank System Checklist (Type II-I� System Type: �
Notes:
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes: _ ���+'v�p T� � V� �
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I����-�� � ��¢�.I! IE���.71�1�.
WELL Y'EY2NdIT
PI.EASE SE� A�"I'ACfIED PLAN FOR WELL SITE Lt�Y�UT
Tax Map #: ��. Parcel # 'I'ownship ��a� �'v�er
Applican� ��t rn ni� �%t✓%.iz.4
Subdivision: ���"�a�se �/�_: Section: � I.ot �C7
Location:
, / A/. �/J_ . i/ o / _ / � J, % / /� ,/'J / /1l ) ' _�_ C/�
0
f
'I'�e of Water Sunolv: � dividual Community Public
Requirements•
Site Approved by J
Gtouting Apptoved bp
We1T Log
We31 Ta S
.A ir Vent
Hose Bib
Concrete Slab
„.
_Z�.��
Well Driller. �,���g:
^
Well Approved By: Date: Z-Zg-/8
�.
'�°5ee Attached Site Sketch�*
Wells must be 10 feet from properry lines.
We11s must be 140 feet from septic systems.
Welis must be at least 25 feet from any building foundation.
Other conditi
�
�
PCF-ID, rev. 09/07/01
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
_ �r1 Nd�J �- ��• 0� � c.t..r -�'"
Wcil ContraGor Name
����G --�
NC Well Contractor Cercificazion Number
Barnette Well Drilling, Inc.
Company Name
2. Well Construction Permit #: /�/ / D
List all applicable well construction permits (i.e. UIC, County, Stale, Yariance, etc.)
3. Weil Use (check well use):
Water Supply Well:
�Agricultural
]Geothermal (HeaunglCooling Suppiy)
� IndustriaUCommercial
�Imgation
Non-Water Supply Well:
�Monitoring
Injection Well:
�Aquifer Recharge
�IAquifer Storage and Rewvery
�Aquifer Test
�Experimental Technology
�Geothermal (Closed Loop)
�MunicipaVPublic
�x Residential Water Supply (single)
�Residential Water Supply (shared)
�Groundwater Remediation
�Salinity Bamer
�Stormwater Drainage
�Subsidence Control
�Tracer
(�Other (explain under #21 i
d. Date Well(s) Completed: -�� L� Well ID#
Sa. WeU Locarion:
.f��/l2 y �,��vl�� i��t' � -D f � LS
Facility/Owner N e Facility ID# (if applicable)
� d�- � d o/�ti'. R; A s �c ��s
Physical Address, City, and Zip
�e�2sa.v � �O
County Parcel Identification No. (P[I�
Sb. LaNtude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
.�6 - 3�66 Z� N 7 g- D 2 Z. �'6 w
6. Is(are) t6e well(s)�'�rmaneat or �Temporary
7. [s this a repair to an ezisdng well: �Yes or �No
If l/ris is a repair, fill oul Amown well rnnslruclian mjormalion mid ezp[ain !he nature ojthe
repair under »2/ remarkr sectian or on the bock oJthis form.
8. For Ceoprobe/DPT or Closed-Loop Geothermal Weils having the same
cons[ruction, only 1 GW-1 is needed. [ndicate TOTAL NUMBER of wells
drilled:
9. Total we11 depth below land surface: � L�� (tt.)
For mulUple we[fs list a11 depths ifdiffereru (erample- 3(n)Z00' and 1Qa 100�
10. Static water level below top of casing: 25 (ft)
Ijwaterlevel is above casing rcre "+"
11. Borehole diameter: h (in.)
12. Well construcHon method: Alr rOta�/
(i.e. auger, rotary, cable, direct push, etc.)
14. WA7'ER ZONES
FROM TO DESCRIPi'[ON
� rt � l� rr. la S�r�-
L� rr. r . �rr. ;Z S'�2�.,
I5. O[37'ER CAS[NG for malti-cased weils OR LINER if a IicaWe
FROM TO DIAMF.TER THICIINFSS MATERIAL
p r� �"'p ra 61 /8 �o. S�� 2 �(i �-
16. INNER CASING OR TUB[NG eothertnal closed-lao
FROM i0 DIAMETER TFQC[Q�IESS AtATF.RIAL
R. ft in
fG tt �a
17. SCREEPi
FROM TO DWMETER SLOTSIZE "['�CIINESS MATERIAL
� ft ft ia
fw fG �4
18. GROUT -
FROM 70 MaTERIAL • EII�LACEME�IT METROD & AMOUNT
p « �, d� GraveUcement poured
k. fL
ic [c
19. SANDlGRAVEL PACK �ta 6able
FROM TO MATERIAL EMPWCEMEIVT ME1'ItOD
ft. fG
ft. f�
20. DRILLING LOG attach addiAonal sMafs if necesss
FROM TO DESCRIP7'ION rnbr, hardnas, aoillmck 'o sae, Nc
sr. Z �. v d %L .6
Z- " � jr �. e � `
S � 5o E� :�� e �Sv �`
�i� � %� f� S/T�v'NJ 5 U
d fk �� f� �/�%� �L.
t4 ft
fG ft
21. REMARKS
22. Certification:
� v��c.e., � . �°�,-�. - 3 /� /8
Siguture of Catified Well Contractor Date
By signing this form, I hereby cert� that the we/!(sJ war (wereJ constructed rn accordance
with ISA NCAC 02C.0I00 ar /SA NCAC 01C .0200 fYe!! Construction S�andards and that o
copy ojthis record has been proviJeJlo lhe weU owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or weil
construction detaits. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Welis: Submit this form within 30 days of complelion of well
construction to the following:
Division of R'ater Resources, Information Processing Unit,
1617 Mail Service Center, Raleig6, NC 27699-1617
24b. For Iniection Welis: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the fotlowing:
Division of Water Resources, Underground Injection Controi Program,
FOR WATER SUPPLY WELI.S ONLY: 1636 Maii Service Ceuter, Raleigh, NC 27699-1636
13a. Yield (gpm) �'S Method of tesr Blowed 20 Min. 2a�. For Water Suualv & IniecNon Welis: [n addition to sending the form to
. Chlorine •1/4 Cu �e ����� �Ove, also submit one copy of this foan within 30 days of
136. Disinfecdon type. Amounh p wmpleGon of well construction to the county health departrnent of the counry
where constructed.
Form GW-I North Carolina Department of Environmental Qualiry - Division of Water Resources Revised 2-22-2016