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Applicant:
Location:
� � ,-,
Psrmit Valid for �ive Years
Type of Facility: ,:
# of Occupantsz # of Be�
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
T�x I��� � � P�,rce�l
s�Ubd��►.s�o►, v � ,
Phas�e Sect;ion: Lot # �i � �
�
�nprove�ne�t �'er�t
No Egpir�tion
Owner or Legal Representative Signature:
Authorized State Agent: � ,�
j'� :'✓�;,T�
�Addition V�ater Supply e��i/
�ily Flow ^ ��d.�s- io-a5
' Type: � .1[ c, _
Type: •�'� 3I'Q
Date: g"� -d�
Date: o �/ 03
The issuance of this permit by the Health Department in does not guarantee the issuance of other peimits. It is the responsibility of the
applicant/property 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 ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules �'or Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Iiealth
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable. _ __ _
Authoriza�on to Cons�uct Wastewater S�stean �Itequired %r Building Peranit)
* See site plan and additional attachments (�.
Proposed Wastewater System: ��.v'�vi7;�'dn� �
New � Repair Expansion
Type of Facility: -� .S',i,�/e �-r'r�w,` y !�p_S"r'o�'.r���
3��..'. —�
ank Size: Septic Tank: ��c� gal
irainfield: Total Area:-�Z�sq ft
3(00 Cs o-us
Type ��2 Wastewater Flow �.p.d.
Soil I.TA12: �.� g.p.d./ ft 2
Basement Yes �No
Wastewater System Requirements
Pump '�ank: gal Grease Trap: �-- gal
�j(�b
Total Length � ft 1Vlazimuxn Trench. Depth 30 an
�rench Width �_ ft 1Vtinimum Soil Cover: 6 in
Distribution: Distribution Box Serial Distributton
5pecifications: �.� S� p� ;��,/ R�O
Authorized State Agent: d�!-
Permit Expiration Date:
Minunum Trench Separation: � ft
c/ Pressure Manifold
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te: ld - I `�^d �
— S I o S C1•��Q � -te �u � ' `�`-
The type of system permitted is � onventional Innovative Alternative. I accept the specifications of
the permit. ,/
�wner/Legal �t�prQsentative: N � Date:
g- /.- �s �
P�HD 1 / 17/2003
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Tax lYlap # A-�fa Pascel # 37
Section/Lot# ��
' S-/� -os
Date .
�� Systc�r�i com�ionen�r represent ap�mximate�contaurs onl,y. T.;ie contrdctor must, flag the system priur to
beginning the instaAation to insure that propergrade is maintained :
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pG�, ;c7. 09/12/U1
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Applicant:
Location:
�x M�p � I I Parcel #
Subciivision � � . , - � �
Ph�se Section: ot # � ;
# of Bedrooms
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u
„� � � � : �
System Type (In Accordance With Table Va): e�ra�r'�
TH1S SYSTENI 0-1:4S �EEN INSTALLED If11 COfViPL1ANCE WITH APPLICABLE NORTH
C�4ROLIRlA GENER4L STATUTES, RULES FOR SEWAGE TREATNiENT AND DISPOSAL, •
AND 0�1LL CONDITIONS OF � THE !tU(PROV�NIENT PERMIT AiVD CONSTRI]CTI�N
AUT Z,4ilOi�i. �
� �'.��'�S -
Authorized State Agent � Daie .
Installed � Date: �- 3�'�,$r '
.,�e � �
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PCHD, rev. 07/29/04
�
�E��iC °�'AN� IG��P���°3�� C�$E��C�9��'°' �'Y�e "IB - �)
Tax Map #�_ Parce! # System Type (Tabie Va)
Owner/Applicant Subdivis9on aK ' r
Address/Location Se�fPhase Lot #
� State�ID/date � - Z
Ca acit 5- 0
� Tee and Filter
� Baffie
Sealant
� Riser if a licable
Tank Outlet Seal
Permanent Marker
. Pumt� Tank
lSealant
Riser
Water Tight
' f lJi'�i�
Checic Valve/Gate Valve
Ant�-s�o on o e
renct� �dth � ; � ft.
rench Depth ,3 �) in.
renct� Lenath L��7o ft.
Grade �
Rock Depth and Quaii
Dams/Stepdowns etc.
Pressure Laterals �
Hote Spacin4 �
I. Pi e. Sieeve
Tum- s/P.rotectors
Ftequie�ed� Set6acic�
From� Welis �
From Propertv fines
Alarm (visable and audible)
Electricai Components
Rate (gpm) �
Approved Pump Mode(
Bloc� Under Pump
Pump Removal Rope/Chain
. � Distribution. Systern
Serial Distribution p-{,a,
.
ressure ani o �
Low Pressure Pipe
Appr. Pipe It�lateriai and Gra�
�
�
�
Surface Waters
Public 1Nater Suppiies
Vertical Cuts (>2 ft.)
Wa#er Lines
Vek�icle �Traffic �
� �Easements/Ri ht:of W
Othep
=zl-r�� Easements Recorded
Coanmen�
0
pcf�d rev. 3l13/0�1
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P�SE SE� A'3"g'AC�iED PY..�N �Oh� WEI.L SI'I"E �Y��J7C
�'ax lO�Yap #: � � Q Parcel # 3 � 'F'ownship ,�/a � �'v�e:�
Applicant .�� f%L✓�S�izs
Subdivasion:. `t�^�'c�s� fll'r�� Secti.on: I.ot: �`f
I.oca�ion• • �
i % �%' r/% o // 0 � �' /�` l J. �/ / / A / 0 /!�' 1 � _�_ �'�i�
6 % s � �
c
'I'y�e of Water Su��l�, �Individual Community Public
Rec�eagrea�aents:
Site Approved bp �_,_.
Grouting Approved bp 3"
Well Log SS
W�t T '' �-3 l- �S
Air Vent -�5
Hose Bib S�
Concrete Slab �s . f0 � S�s
WellI2riller. �Atn�.l-�-�
Well Approved
�See Atiached Site Sketcfi�
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp building foundation.
Other conditi
� �yircz�6
PC�ID, sev. 09/07/01
. ... . � .: . DD U WOC3U �DD Lr r i ( � .. ' .
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�� �♦ t.. Q Q M.fi elj' n'Ya� ���-�`CJ�✓
�:� �� 1L � '` � u.u�,uu�
�snwna-o�a�n*�+ ��rn.�.ffi:� ����.��.� . LXsllSl� LNll�UI�I°J � ��`�' ' �7
rJ Grout Log
p��; �p..�,,5 d�� v� S Tax Map Parcel #
Location: �
Subdivision: 2�5 Lot #
Well Constraction �
Distance From nearest Property Line (Minimum 10 feet) � �
Distance from Septic System (Minimum 60 feet) /�J
Total Depth: �C� ft Yield: o2CJ GPM Static Water Level: � ft
Water Bearing Zones: Depth fOCQ ft/�c a ft%�� � ft� ft
Casing:
Depth: From � to �% ft. Diameter: �_ in
Type: Galvanized Steel
Weight: Thiclrness: ���� Height above Ground: l�/ in
Drive Shoe: / Yes No Any problems encountered while setting casing? Yes �No
If "yes" give reason•
Grout: �
Neat: Sand/Cement Concrete GraveUCement -�
-. Annular Space Width inches Water in Annular Space Yes No
Method of Grout: Pumped Pressure Poured !' Depth C�� to s 2� Ft.
Materials Used:
No. Bags Portland cement � Weight of 1 Bag Pounds
Liner:
If mixture (sand, gravel, cuttings) - Ratio to
ID plates: �Yes _ No 4 x 4 slab �Yes _ No
Depth:
Date Installed: Grout: Installed by:
Drilling Log Location Drawing
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 Department. ��
Signature of
ID # ��8 Date � � 3� � �
Pnmp Installment
Pump Installation Contractor: s-�i?'� o-(_ w L9.� State Registration Number: %��- ��
Pump Depth: d� ft S tic W ter Level: c� S� ft I
Pump Make & ModeL• c' � Pump Size and Rating: �� hp l� 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 th_is record has been�rq�yided to the well owner. .
Pump
Date: �3� �Q PCHD rev O1/27/04
��
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PERSON COUNTY HEALTH DEPARTMENT
355A SOUTH MADISON BLVD.
ROXBORO, NORTH CAROLINA 27573
BACTERIOLOGICAL WATER SAMPLEANALYSIS
Name of Owner or Tenant `� �P ��� `� JP��p�`�/ S
Address S � �e^S �? y � vP - County �e r' S c� �
}� ���(P %l.�t�llS
- L����
Collected By � d� d�� `� ��'P�� y
Date Collected d��k�b y Time Collected �v ����—r
Source: ��ell ❑ Spring ❑ Other
Location: ❑ House Tap ��ell Tap ❑ Other
�
ONo Charge � harge
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Total Coliform
FecaVE. Coli
Present
❑
❑�
Results
Absent
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T�
• . .
Reported By � .
� Ca � ( Q � �' `� �.(' � /^Ps� li'S %v � � � — $' ��-- � C�vC�
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