Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
A40 8
Person or firm doing installation: � � � ��/ �/� t/. / t�4' _ l�o ,r �76 x9 — � bedrooms 1, 2, 3, 4. No. of persons to be serve Additional appliances to be used: Disposal, dishwasher, washing machin � �,Y ( -- Septic tan Minimum Requirements: --- . ` ^¢ �{ ,�l �ic L f % /f n� / �/B ��� Y Nitrification line: Septic tank and nitrification line musi be inspected and approved by a member of the Health Deparlment siaff before any portion of the installation is covered. � Date Approved: By: Countersigned ( B ' ' an' rian / O. David Garvin, M.D., M•P•H• District Health Ofi'icer (Over) A 1953 P ON COUNTY HEAL`TH DEPARTMENT WELL , LOCATION T PERMIT Tax Map # _�___� b Parcel # � � Zoning Township Owner/Contractor._��-� -, Date �/- 27 �oo / Location/Address,�� � ,�� - S.R.# Subdivisiori Name I ayout �1 � 1£ _ _��'LI VN Z �� � i� ,���S�s �� � ���c y�' � o' � � x �G�` -�. U�13 � W� TO �u2v�.� �{�1 Lot# . j As Installed ��r Nf�i'�' : �1�7 W�'iGL �✓�tXi� �'� ��'°P��G y �a�.c/vo.��� �D Cqu y�v-� ��r �.�2 G.('�rr ,B,v',n �i�✓.� �.t�s��nay �}�'9�-�790 SEWAGE SYSTEM SPECIFICATIONS • ea i e Home �ss ooms______ Size of n� Size of Pump T i n ication Line Max Depth Trenches Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is altered or intended use changed. �nd Septic Layout by � � Comments: y�/� " P r� -��rG�� E� F�- - Date Installed by Approved by. WELL SYSTEM SPECIFICATIONS idividual � Semi-Public ublic Replacement�� ite Approved � //- Z'� Jell Head Approved �routing Approved !/� ?� _•(,��G�i Comments: Date Installed by. Required Slab Air Vent Required Well Lo� ��-z�' Well Tag i�- 2fa' Approved by. � This report is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this petmit The environmental health specialist is not responsible for false or misleading infocmation contained in the application The environtnental health specialist is also not responsible for concealed conditions on the property or for statements in this repoR that may have resulted from false or misleading statements provided to him in the application Neither Person County nor the environmeMal health specialist wazrants that the septic tank systetn wili continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\pemut.sam 01/95 rev.1.0 ORIGINAL rao�-a6-oi o�r58A �.02 Anolication Dat�: I� °2 ��v � Tax P�aQ rl_,_ Amqu�P_�id: _�___ RE'C81Df �: Parcel #: .. V,—� �,�� .1�� S� I�I��.��� "' � � "`-� � � �T �'�` �),.r � „r�:.a—.��--,.-...�,��.�.�a �,_,.�,.���s APPLICATIOM FOR B�RVIC�S � 7j Permlt re�u�e�ed by: {Owner/ag�tnUprospQctive� otwrr�rj: `� 1�1� Fi�me Phone: � - Address; Business Rhon�: x) �lame a�d Address o� Current owndr: - n,�bY�O��g,�(�i _'t'w 3) Prc�erty Desc�iption: Lct size: ,�f� Tawnship_ Su�divls�on: Directions to the prop�rry ((nduding roa� �ames,�d,nur�b�rs� 4? �7 Loi #: c,�f S 7, Prnpossd Ua�e ar�d Structure Description: answer e�ch af the following questivns: a} I�rqpased ,, Existing _,_,, Type of 5trut�ure: _ ',Nidth: D�pth; ^. b; htumber ot Bedrooms: Number of occupants or peGple ta be served: _--- c; aasernent Yes �, Nn _ Wil! there be plumbing in the basement? d) Garbage I�isposal: Yes _, Np „�„ Wabor Supply Type: P�ivate,� (new ar existing �, Pubiic_, Co►rmur�lty ___, �prin�,r Are any wQils on adjoining prpperty7 Yes ��!o � lfi,yes, ple��e �ndicat� a�prrsximato locatinn on tFt� sile Q��t�. 6� Do� tha property contafn previ0usly idenWfad ]urisdicilanal virastfanda? Y�s ,,,� No � P�EAS� hIQTE TH� F(?�.�.t�Wi�IG: Y�► Pir4T OF THE PROPERTY OR SITE PL,pN NtUST B� $1JBMITTED WlTH THIS APPl.1CATiQN. Y PRQFERTY L1NES ANU CQRNER$ MUST BE CLEARl.Y 1YlAl3KEt3. S� TNE PROPO$�p LOCATIOK C1F AL9. STRUCTUFiES MUST 8E ST/�IKED OR FLA�G�D.' � THE S1Y� MUST BE R�1IDILY ACGESSIB�E Fi}R AN EVALUA710N RY iHE HEALTFI [7��ARTNlIEhl7 �u'TA��. i��erehy make appi�cation to the F�erson County Heatth i�ep�rtment far a site evaivaticn for the on�sit� se�raye d�spasal �ystem ror khe above-described prop3ciy. I a�ree that the conlents of tt�is appli.ation ar� trrae and repteSent the maximum facifities tn be placed on tha property. 1 understand iP the sfte is �Itered cr the intendad use changes, tt;e p�rmit 5h�ll �oco ' valid. _ � � wner or L�g�l epre t tive � Dat� PCND, rov.10117/at i�i:�;,uii �:unt� rv i;i��� i kuI1P11• IJ I'AI. III.AI.'1'll � I��►I�: __._i_('.�'.�-d� c:��v►��r: �'�-_ � cv► � ' 1 �-}z, --.-- -c�d_. .-_----.__c_ote C �1 n _ . . _.._......._. __.---�- f.c>c��li��ii/I�)�rccliui>>:..5_��%�... f-1�.�e.�.�...1�-�u.�_.Rc�._.. . ._......... .._... .51:11 ._.--.___ .----�--- ..._... --��------- - -�--��--��----�_ _ ._ _ _. ___. __.._..._ _ ..--- --........_- .- -�-- -... . . .......__ ---. ._.-- - �--------- ------- _ - - - Sul�clivi:,iu�� N�iiii�: - ....._--.... 1�)rillin�; C'c>nir�c(c�r: -- -�N�� ---- --�--�--------- ---- (..c�t 1�------- -- -- --- - �.. __�E�--- ---------- �-----.._ ti'��f:l.(. c-'i�N�"ffZt1CT1ON ------�--------------�------- 1)is�.���c� t�rui» i`Jcs�rest 1'►u�>�r�y I..inc.---��------ I.)istaiic� trc�i�� Source c�F I'c>llulic�n , � -- �------�-�-- "I'ut;�l I�cl�il�: Ia� _ l�t. Yicici�• ��) C;I'I�•i S�atic tiVa�c:r I..cvcl tiVaicr 13e��i in�; L�iics: I)� ►�l� a, _�.�__.__._.Ft. lJ ' ! 1-1.--..---j'�� 1'�� 1't. l�t. f�� �'asing: l��j��l�: 1=rc�n�_ _I-�cc� __(��------- — ._ � _ 1't. 1)i.��ne�er: �%� Ii�ches 'I'YPE: Slcel _.-------------------- (,alv�ini�ccl S��cl ��' --�- I1� S���l, ciu�:s uwn�r a�>��rc�vc• �'c:� _.�/_ Nu--------------�---- 1�Vc:i�;lit: ���liick�i�ss: �1��_.l I�iblil rllx�vu C�rc>ui�cl: _ ��` Inches --_— -- - l�rivc Sl���c: Ycs.. _y� _ TIc� - --- -------- � W�rc 1'rc�l,lc���s Lncc�t►��t�rcci in S��tinb tlic; Casin�? Yc:s. --•------- ! �„ .: .. �.. . -------..._ TJo • . �l yc� ��v� ic:tisc>��: .- .._..�----.. �rou[: �1�Yl�: I`Ical...--- Scincl/C:�ii�ciit----� �---------- -- __ _ _ . - --- - C'c�n�rcl� , Annular S��acc ti'ricl�l�_. _ .� lit�i��s � �--- Wa�cr i,i Annul.ir ��rice: �'�s --------- Nc� X 1vlt:llic�cl: l'u�r��x:�l_,------ 1',�ssu�� � � I'uur��l ?< 1>ci�sl�: 1'fOlil.-----•------•---- l(> ------'I'[ •------ Matcrials lJsccl: 1`1��. I3abs 1'c�r�lanci C'�i»�ii� tiVei�;l►t c�f 1 l�ab ll�s. If rnixtiirc (s.�i�cl, �rav�l, CUUIIIcS� -(Z�SIIU' p�-` lU 1 —�. 11) t'lulcs: �'`�5.-- x i`tt� -- �_ _ .. _...- --� --.�_-- -- �I x �� st<<t� Ycs.__------- r,c�---- ----- ------ -:- ---- .--...____._._._---.._�)RiI.1�l1�J�; [.Ck; I�c �tl� --- -- ----------._._-----..._.--�----- .�_�_---�--- -- ----� ---�--------------------__..._-------------�-- ----�- --------�- :.�:- rrorii "I'�, Pc>iin<<�ic�ii 1)�scii �tic�n � � :. — - O -�----- - -...._ ----------- ------ ----- . .. . ......_. ---- --�-- q _. .. ---_ .. -- -- - --..._ .. _ - � �C� . . . . .. _ . _ ., - .. a � � . . .. _ .---.---.- .... :�._��- �_.. � �-- .-.--_ . _ . . � � -_ . _ . . :�. . _ ._ _ -- -. -.. . . . . --- .----.-- . � - � _ __.�-.-- -- --�- .---�{-1 . �r��en_�ne..._ ._ ._ _ .._. ............ .. ..... ..-. --- �-------- `� I l L l ---. - ---�R����. .... -- .--�-._.. . . _. -- � ___ _.Ll._... . ..!.). - --. . �R�-i� . .. . _. . _.. _ _-- --. .. _-- --- I1 a �a5 q�a„���.:: - -�-- --..-._._... ..... ---..... .. __ _.._..----.---. -- Y �tt.�Zr_•t3Yc.1.�t't'ir�Y���tl���i��l't��: n�;c�v�:lr���ol�,���,�'i�lc:)i�1 �� C:U�t�tt�c�'t' 'l'l�Is W1�(.1.1�AS Crc ��•JS"I'R11�:'I'f:l�) 11�1 �1c�C'c.)lZl )�1Nc,I: \�VI"l'l l ll1:c �IJI..A'I'IONS,SL•'I' T�C)It�i�I11iY�"1'lll.l�►:I;�,c�iJ�'c:�IJ��J�t��� lll;�t:l�tl l�l:I���It�l�t�-f1.rJ�t�. �-� �� %�?�c r� . 11- Z 7 -U � ���;��;►����� ��r������<<.��:��,►� . . _ i �„ �:. I'I:I(;iU(1 t:uIIN l'1' F:1l1� I I:ullFll• t! I'rll. III.AI.'i'It � ��(li��. __...1-t _���?`�.ti (.)wtic;r: � , , � �. . .--���.'L,,�.. � i�.' �CL 1C, ��L�Ii�C...`Y� )�\f� . ... .._.4:,-, ,-..j.... . . ... . . r_.___..._. -------- • ._._._..... .._... . �.(>Cill!OI1�� )1!'C(:l Ic)Il:i: . .-.... :L�;.;:�.... � "_ '; `.=� ,�.� , J --•---- -----•-=— ......- -- � ` .�:`�.u.1.i..... :. . � ^ � . - ,,.,r ,--....hC�.._ .. ._. .. .__....._ ---•-..._.._•••---_. ..._... ----•------ - ---•---••----�•- _ •- - --�----••-�-�— - S��lxlivi:�i�,�i N<�ii�►�: ----�---......._- --�------........------.._.------------ ---- ....... ......:__.... . .. -- ---,-._ -�------------�--- . . , : : ---- -- ------ l�)rillin�, � ; , -�-------...--------------- ..c�t t --- -- r �_.OIlli�<1ClOf: �--!. ,`� � -- -. s_.. ... =:=�=.'r�`_,' -$.. _��:I ��----- -------- 1�' l: i.(, c-'t��N �"flZ ( lC"T'IO1�i ---___-------- ----------� l)is�,�nc:� t�rc,in I`Ju,irest 1'iul��rty l.,iiic----��_----- l)istlUlCt; ri"011l SOl1CC� Of 1'c>llutic�nl--(,�'--------,-.-- ` . 'I'c�t;il I�cl��l�:__ � �,� I�t. Yicl<1��. � �'�� � ��tl '; �_'___'._,•--- <.,i'i��i Static Wat�r I._evcl_�.� Ft. 1�Vat�r T3e,�iin�; l�nu5: I) `� �''` -- ( � � �� _..---�'�• �'�- 1't. l�t. Casitig: Dc;�>tl�: 1=rc�it�_---}-�Ic� ---------- ,,� '('YI'[�. . -----���-rc. I?i.une�er .__.� � _._1i�ches ' Stcel----�------------�--------�'alv;ii�izc:cl Stecl . �---�" IC Stcc:l, ciuc:s uwrt�r a�>��rc�vc: j'�5 jd�� —' ___.-----.--- 1��/�i�;lit: ��.., ---.�-_--• -----�--- -��s't�)iick�ic:ss:__,ty�S;° .Ii�ibh� Alx,v�: �,rc�ui�cl: _ i"�„_ Incl�es »���� si����.: Y�S._.-x _ r��� - . W�re I'�c�t,l��,�s I:ncc�t,����r�ci irt S��tinb �I�� (;asin�'� Yc;s.---- � �'--- � ri� ._�= - �, �� ..yc�" �iv� i��iSc�u: ----�-•- --- -... CJrout: �1�Ylx:: Nctit _____ ._ Ssii�cl/(�:��i�ci�t �_---- �.;onc:r�t� - - , Annul�ir S��acc V,li<I�lt----- '� 1n�i��s r a ��IlIL'I' 111 �t11lU��lf ��)�1C1;: }'LS --------• NU x tifethc�cl: I'u�nEx:cl_----- 1'ccssu�� � _ ['uur�cl � ---------- — I)L�)iii: 1'(citll- - --•- ----- tc) •------ - r�. Mat�rials [);;ccl: j`Tc�. I3abs Pc�rtlanci C'�n�c��t _ tiV�i�;li[ uf 1 l�ab ll�s. It lr�ixturc (sar��1, �ravel, cuttin�s) - lZatiu: e�—` �c� 1 _. 11.) t'I.�tcs: Y�:S __ ): j�lc� ----_...._...---� --�----.� �I x �I sl<<l� Ycs---------- I'J<�_---- -=-- . t)IZii.i.lt�d��� 1.(X�, -�----- — ----- - - .. ..._ ---�-�-------.______----�---- r)c xli ----------._..------..._..-�----- . --�----� ---.. .._._.�--� -------------------------•-------------�------ ----�--------=---- rrarii 'I��, . .__._._..------ -....rc�i�natic�n 1)�scri�tic�n — --rA�� --... . _ ..; — -� _' __ e, i � it`Z 'S . . . . . ... . ... _. �"� ,, � �.�i . .^ ,.,_ .. _ .. � . . � � � ,� � � - , . . . . _ . . ... ' �{q � t � . �� ;J'""_ .-. `✓� .r •. "' .' . .. �. -.�: j!� ��,,.Y��: .�..J . . _ .. .... . _.. . .. ._ "•_"_" _ . _ •'1 „� - � , --- ._.... . .. •-.-- -- -•-�-.. . . ,-� � � ""_) ,—. . - � '� 4 <"� Tv ... ts � . � .� 3 . ""' "'___'__._ -- --- %.....,.__" _' "_".._.. • .... . . ��!^' ._�"._j�`: - �� :L...� , i - � -�- -. _ _ .._.�`�_ a , t i _ __! �.,�ii--s 1\i�-`---��'-.i .. ..._... _. . _ ...._. ......_.__.. .. .._.._ ..--- --.._ .------ -- --- - - ... . _ __. ._ ' •i � ! � . _ �. --... __ ..,._._... _ _.._. _. . _..._._ _. . %; ; , ' � -------•�..--- ' —. .�_..��.__.... ._ 5.9.::s, __. ...._a _:�"1C�1� • • � n „� � ... ._ _. -�-- -- �-•-•-... . ...---._..... � , t � _�; !_� a�C;l���. +- � .. .. -- -.._.._.__.___...-- I III:ItC�13Y (;I�(Z'1'I[��''('l1�1;1"1'I11: Ali(7V1; l��I�01��1•(r�"I'((.)j�j l� C:UIZIZI:C.. 'r���s w�.i.�. wf�s c:c �r��5�i �z�rcY���:��� irr �c-���c»z�:�.�r��.►: w��i��i �t�.c �i�i..A i ic�ri��s�i •i� t'OiZ'I'( I I3Y "1'! l l: i�l;h �>c �i I c�c:�IJTJ'1'Y (11:�1I : l'( ( I�I:l���k"!'(�-11:rJ't'. .', ., i ; _ �_ ._ ': �l�;t. ;�; �i�;ti�itui�:� c,� ! �c�iitr.ic:l�,�. �� -, _ Application Date: l o?-4-D 8� p0 7, �7'� 7�lf 3�— Tax Map: �� O Amount Paid: � 50 .00 sC� • s Parcel #: � Receipt#: �E `10 3 l �# � $�,`� , `������ � ���� �� - ,...,_ � � � � �' � IL�. �xa. -s �i iz-.ca lza. ,•-••-„ <e� �ia tt:.rn. 71 IE 1I <e=-.sa 11 ti:.�a Application for Services (Septic Systems and Wells) Services Re uested ❑ Improvement Permit (Site Evaluation) ❑ Construction Authorization $200.00/$300.00 (if > 600 e d) (Fee is de endent on the e of system ermitted) D C'�obile Home Replacement or Building Addition ❑ Permit Revision $150.00 (if site visit re uired) � dc�; n �L ►ec� f�oo +�-. $75.00 ❑ Well Permit (New/Replacement/Repair) " � Repair of Existing Septic System $300.00/$200.00/$75.00 No Char�e 1) Services Req sted by: s,q, �% � 5,�,�s Name: ��jj,�r� C�� �o C/� �o•-,,s�' Phone # (home): Address: , iMo t (work/ce(1): S�� - I s S 3 Fi�c�m /J �573 2)Name and address of current owner (if different than applicant): Name: �: a� l✓/� �F.�/�/ ` Address: s'9 �j(o /�i��d/c /'� /-J 3) Property Description: Lot Size: Address and/or directions to Property: � Subdivision: , . ��S ^ G1 o w't' o-F 4) Proposed Use and Type of Structure: Residential � Business/Type: Other Number of bedrooms �/ Number of people served (seats/employees): Basement: Yes No (with plumbing: Yes No � Garbage disposal: Yes No 5) Water Supply: Private Well ,%� (Proposed Existing _� Community Well: Public Water System: _ Are there wells on the adjoining properties? No _ Lot #: Yes ✓ (please show location on site plan) � Note: A completerl application must also include: ➢ A plat/site plan of the pro erty tltat shows property difnensions and the size a�locatio�z of all � proposed structures. � �p' �,,,� � `,�,��f,� � p���,,,�.,;? �, �o f- S�e Af i'c,� �� ➢ A signed copy of t/ze `Lot Pfeparation' form ver�ying that tlie �rop�ty ts reridy to be evaluate�l 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. �, Signature (Owner/Legal Renresentative): � Date : 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) r . � P SON CO UN'rY HEALTH DEPART'MENT WELL � , LOCATION T PERNIIT Tax Map # � Li' C� Parcel # � 7onin� _ Township Owner/Contractor Location/Address Subdivision Name Lot# Iayout j1f���� I'���,/�� `}� d {� l / �,.5.�� � �1' rt� ����� �� �`��o f� �u,pi�'�� �� e�``7�i�� � �0 � � ���L ,� � � r��� 3Q _ �� �y gc��� � �..._— ��" ! `� � 9� '—� i.aN�=� � � ' i.zlr.� •Tts �;2a�� �+� A 1953 Date �� - 27 ���� / S_R.# As Installed �11�� : c�� :��.�.� >�.�, � �� ' �<"�'f��:�t� +����c'l��r%� �� C.�, y�n� �%�'� :� G�c�:;�'� .� 'r'!/�.�?''�.. ;/✓����>;7t.�,y' ��������� SEWAGE SYSTEM SPECIFICATIONS ir _,---' ea i e Home iess ooms ___ Size of Size of Pump Ta _ i n cation Line Max Depth Trench�s. Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is altered or intended use changed. � WeJ,LAnd Septic Layout by ��,�, G� _ Comments: �rt..� ,�:��� �'� " � � ��.� Date Installed by Approved by WELL SYSTEM SPECIFICATIONS dividual � Semi-Public Required Slab �blic Replacement—�� Air Vent te Approved � /f •' �`� Required Well Lo� E�-� � ell Head Approved Well Tag ;�-�'' routing Approved d1 •?s�_ a� c� Comments: Date Installed by Approved by , 'Ihis repoR is based in part on infonnation provided the homeowner or his/her representative in the application submitted for this per[ni� e environtnental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resuited from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist warrants that the septic tanlc system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\pernut.sam O i/95 rev. I.0 ORIGINAL ' �� .� ��� ���� . �.'} 1 ,� ��I � , �� �r � I � �' �� ��� ' " ��-3.�L <o�^+ �*�Tr-+ <B3n.�.S1.�. ����.J�'�� • � � / . T� x M a p ��.r �ei � Su:bd;ivi.sian � � �:s�e: S�ctian Lot . Applicant a / V � � � �vi� . : Location: �}v�dl P M tI! s� Q S9 `��a u��v�e�-►�l� (Z , _ i�apravement �ermit o^� d��� ra;.,.. ' . ��rmi# °dal'ad for �ve �e� ` Yo i�ation . . �► a �'� ��•, q . Type of Fa�ility: 3,B R S�� � New Addition � �ate� Sn�p�ply �X �� P J �; . � of Oc�upants (o # of Bedrooms � Proje�te3 Daily Flow 3�z� g.p.d. Proposed Wastewater System: �� ue�� 3� i � U�-► Type: ��� Proposed Repair: �o� v P� 7���-�. �o u^.. „(� Type: �`_:,?��_ p�t�c�a�tio�: �� s;�4-e 5'kp�� �-,, — . Ownez or Legal Representative Signature: �_ . Date: 7 . _ Authorized State �Agen� - Dafe: _�/, �/O 9. � � The issuanc� of this pe�it'by the Heaith Depatmient in does not warantes the issuanca of other pem�its. It is the responsi`bility of the � applicant/property owner to in sure that all Person County Pla�ing and Zqnmg and Bnilding Inspeciions requsements are met This �nprovement �ermit is snbjetf to revocation if the site pIan, plat or the intenderl use changes. The Ymproveaieut Rermit is not � affe�#erl by a ci�ange in ownership of #he property. 37iis permit was issnerl in compliancs.with the provisions of the North Carolina `Zm+�s and Iiules for Sewage Treuhnent and �rsuosal Svstems' (15A NCAC 1�A .1900). Neither Person �ounty nor t3ie . Enviranmental iieaith Spe�ialist' warrants tiaat ttie septic tank system w�11 cantinue ta function satisfac#orily in the fuiure or'that the water snpply w9ll remain�potable. - -- . - . A�t�orizaiaon to Constraci Wastewater Sys#em (Reqnirecl for Bwlding Per�t) •* Ses site plan and additional attachments (_J. �_- ._ ,j., Proposed Wastewater System:� C� � v�^'t�t�� `• /'` j�'�.� Type� `� Wastewater F1ow •�OD-g:p.d. New X Repair_ Expansion _ � Soi1 LTAYZ: O• 3 c7 g.p.dl $ 2 . � Type of Fac�7ity: ��2 .S �.l� Basement _ Yes o � � . . �aste�at�a� Syst�an �es��iur�ffients . �an� Siae: Se�tac '�anic: �o� gal : Pnmp Tank: ����gal Grease Tzap: �l� gal �rainfaeici: Tatal Area: �a'd � sq i� �Total Leng#it LI"�o ft � Nlaa�nm Trench Depit�i I� in � :. . 'T�encii'VVidtH� �#i �g'i�umu�a Soil Cover. �v . in DTinimnm Tre�ch Separation: ��t ° � i�isttabui$on: �3is�tribn#ion Bo� _ Serial �istrii�ntion ��Pressure NL�ifold Spe�i�icationsi Spe S iS�f S` }c�p 7�C , L}' �'� P b� /C�O e� � a c.�-, �c7`}4 � t�J � �UO 7�t'P`,� c9 � COn ��+� / Gl�i C� Aut�oriz� State Ag�nt: Date: o S/�-b/O � - Persmt Expiration Date: �.��/ a o1 � _ 'The type of system permitte3 is���anventio Acc�te3 Alternative. I ac:.rpt the spe�ifications of tiie permit. • - � .� �w�e�/Y�Egal �ap�es�nt��ve: Date: � re . 11/10/45 , � � ��� s f- I�I�I�.� ��T `—.= � ' � � � �.J��'� C,J,� ; ��; e ][_�nn-s-nn-aaaa�can�e�xa�E.m11 1HL�e.xn.11�ella QWper: ��1�� ((j Ta� Map: f��0 � Parcel #: g Date: OSl a-�/� I�ine �'ap Tap (Sch) Tap �'low Line Lengtta �ow /%ot # Diameter(in) ( m) (ft) 1 �a - �o s �o 2 I/� o S.5 • 100 o,os5 3 % � � • S.5 lo� �,bs5 4 i/a, S. 5 1 0o O.oSS 5 6 7 8 � 9° � 10 �OD ft of line x 65 gal. per 100 ft =�6� a'�o � 100 =�--�0 gal 75% x a-'�7ga1 = 1 �l S gal per dose a'�i` gal per minute (gpm) = Flow Rate Friction Head - ,_ �� � Loss: 1. � 7 ft per 100 ft of supply line z? 7b ft of supply line =100 = g• � g ft 9. 7 S ft x 1.2 = �l. � 3 ft of friction head NIanifold Size: ��� " Force Main Size: �"PVC Total D ynamic �Iead =�� ft of Elevation head + a ft of Pressure head +��°�Sft of Friction Head = a-9- � 3 TDH Pump itequirement: a� GPM @�"g' �� ft of Head. Drawdown: � 9 S �al per dose = 2] gal per inch =`r� a-� inch drawdown per dose ��� ���.� � � ��:�.�� " ' - = �� . , _� '����Iti � - . � : � , � � �� � � � � � .«.»�0000 ;► ;► ��► ��► :::::::::::::::::::�:::;::::::� ........: .................:.....:. :::: - - � Y. .. .. _._ 2" nua Sc3ie�lale �0 �vC � 9 mcua � p � Z" 3ize / # Taps No. Taps off one side �%: for ta 'n both sii 3/." ta s 1'e tat � 5 3 9 5 ZI ZZ � " F`low per Ta Size �LScrterial Floic GPl'YI ;!." Scl�ed �40 �•� . ;; •' Sc}�ed �0 i.i,. 3/, " Sched 80 12.1 \ ?; •• Sched 40 1=•� �,--�.����� ���� �� �._-.. �, ,�-,_, � � � � � � I�,�w-a,�,�,�,r,Y,. ����.Il. IE-3Y��.IL�I� 0 Sloped To Shed Watez b" Cover • � i. In1et Fmm Septi� Tanlc 4" SCH 40 PVC Pipe NEMA 4X Sunples Contzul Panel � '1 +1" X 4" Pressure Treated Post � 12" Sepaxation � E��t�� co�t � 1 , ,�y - • . Access Caver• ,• , ' . ,, ' 1 i • _ �• , I � � r �' • ; • �t• • ' . i �., Opening FilIed With Anti Siphon Hole �,� Portland Cement Cnvut D Hill � � ) Ci�eck , Valve High Water Alarrn Level � (6" Separafion� .. , High Lev�el- Purnp On �� �/ '�VaporLock �i �'�D a�xd�wn Hole T�x M�� � • P�rcel # � � uhciivisi�o�n Ph�s ,�S - ction�Lot # Duct Seal Hoth Ends Of The Con�it —�- 24" Miiunwm ,. ., Tlueaded Gate Yalve • __ - � Zip Co:d Tie> > Rope . % , r � (Up iiill) ,'� . '. ' Low Lavel -Pump Ofi � r• ' �P �• Precast Concrete Tank 4" Coziczete � ;.; (Matezial Strengtk }3500 P$1) Block � �'�;' ' � : • '. . _ r , • ,' . . : ' . ' . ' ' '� . Concrete Risez b" Separation • '•� ' . � %r..r/yf�"' �,�„�._�Portl,arid Concrete Gmut Mastic � . . • � Ope"'"g Filled With Supply ' portland Cexnent Grout Line + • Outlet To Distn'bution 2" SCH40PVC Pipe Float Wire� . � � • f f Floatl� , , • r' .. f.R.ET[WY3ble '••• F1¢at Tree � � r � .. `, 1 _. �. Joov ���or� � T� ���� �n�. �-� C� P� �� �-- `�o' �-.p �F ^s.� n-! _,_ �� _ 4 ' � a ��' , � __ _-- �� -- �et��9 cP e � ' �Pc���^���,��� � ' -�.. ____ � ! . �isfi�� .t�,�� P�-,�p� �r.�S�i /� � W l t� (.� l'f`i �� 4'r� � . � r'P� l}��P I►1� Q L r�� g9//e,� JC� e ����G ��' � � , � g�r1a��� 4��� �,�-, .��s� b ��z�,� � ''''�!^��� �r� as ���t P � agQ. �. wr�/� �a -�e�- .� ���'�' A., } S�� pRo Fos E D � � S�-s're�,, ��� 4�7 S�'i��i� aD�� �L� g�.ARoo�., J J � f L�—_i g�� �pr.�, b H cn Q �O� �as� ��Az�-Lo,,� � ,-- � ���s�ni �, --� �U 6 �L �'LXTST2�1J (, � G� �/VL,g/� wEC L `�' GE 0� �2 c.0�'�, F� _ 1 �` _ _ SC � `� ' , ' � �R �� � � o — -.—�.._ _ ` • _ Sc�� � 6� 14 �31'�� r`•� _ �— — �S s9 � �V ; ` �5s a f _ �3Q 9 � 0 2 S�, �� t � k.��P�,���` IS � �R 35 �60�3� ; �a��� , a �;^ �� ` 15' � �C S� SL,g.CF�/\ r{';y'' PUMPLINE q,ti+.,��, �f'�1 �,"'< M, S N /�S -�� , EASEMENT ��ot�er v^-� �'� S„ �sr'�uP `�, ����/ �� S7g 45 � 62 �..`l l�„E, �'�'�' �t�' q.,.y � . g2„� - - __ �9'4?_"E� � f ' ' - � r �ss ��v � � . . I S ~ _~ - - =� 5�3� �3'3S AXLE S6 lrv �l i. y/ /� J �4 ��� � � � �•�:r' 40, -qA�v . ` � � , � N 9¢ o �g,,F�G� 1 S �,�,� o�, � �b '�t �^'��,� � 0 , ' MPn�S�a � �TQG7�[c IF � 5,�� � �, ,,, � b„r' �Si i s� �, � � � P,� ,�� r{�_.�,- , y t�P �, � � � � f P�o, � " ��l ' : � �,� �. � � S� � � � ,� � :: � / ��f" ;S �co n, � �E%/ = � � ^�^/�r�,d ea �o �- _� ..� ; � '�D a/�1 1%P Qn y lilCa v /� ~ i S I� M M9L�lilP/'y 011i/` � \ � � -� 1",, arry;� �';e�v Qi,Pg � � �6�� \ Q ��"� �'�' . % '3 O , �!� t � \ 99,99`37 „� N\ \ � v ti 1 . . v ,. / C` ` � � � �S6 0 \ � � 2 9`�L � C o� � t�'f ra�c� � �• �`�BS� 2S �� ��' � : � • �3s "�y � � ` ' s � � i� � ` ' , �� �S � ^^ ��,�,,..,r,,�,e� �� , Nso 0 � 9 �C ' ` .3 / � 4 � � � es � �d�' 9 � � CONTROL � �f �'�' P � c,� �p8 p„ � ' � `fb'}t��i., c1 tfUo �2�' o� •,�� • �8 �%' CORNER R�P�-r/� �,� �o�����.;�g .� � NF / Must install septic system on contour. S`� / , Must not install septic system during wet conditions. w^ lo� _'n� ' Septic system must maintain all proper setbacks. �.C.� I I,s, � s, � , Any questions call Environmental Health Dept. �tiL�R(,E,J� p�2� 336-597-1790 �-R E�t �.�Ec.O . sct}c � : ! '= 50 ���,5 f ������ � � . � -- � � �T7C�' IE�.3y-m,.,,.,.,,���.�.1 ]E��..sIlr.Ila � SITE S�TCH Name Q!'i an w� t'� �i e�� Taa Map #��� Parcel # g Subdivision Section/Lot# �� o�. �3��' Z�� d s a.o 0 9 � A thorized State Agent � Date . Sysiem components re�rtsent aji�so.zz�nate�co�tours only. The conhactor mr+st, flag the system prior to begisrning ihe isutallatinn to i�erure tJeat propergnede is maintai�ed � v ��..,����; 1 ' J���?� �� e�� l, � ���. � � ���4�� �r�33'Y1T:O�jc."T.L.Z�����.� ���21.��� Applicant: Location: �� ��� � ���� N � � ���d�ao� PI�,�-���Bo�I�� � �of�e�oioo ,� ':� ��; `' ..� ' �� �� � �`` u .:k System Type (ln Accordanc� Wiih Table Va): ;i'tP � T�i15 ���3�?�i 4-��� �E�� ��9�T,�i.���J 1i�9 C��Pi.l��l�� V�B i�i �i?P�3�AB�.� . hiQRT� i C;�Ri�L9f��,� r=��Es°��L. SiATilT��, §�[lt.�S �t3R ��lli�.G� i�CE.�T1VIEi�T AU� DISrOSAL, � .�ND .-'��,� COf�D6To�i�S �F � T�3E lE�1P�0i��a�E?�T �E��til� ��lD Ct'�i�S � RUGTION Atii�i�i�(�►T'iO�d. . �2 � � �� � � � . �� � ,�ui or e tate Agent t� , - y: Qf� � �� � D . . f nstalled H ��,� d; Date: � � Nttacll Fr t� � �� \ � u►J:vS�' too' � �� � ��-� r• r� ��� J ` � �DO � / ����J�✓�', �v,o�� ���i.r✓y �//9l Ei ��j�� ��� � l�"r[13r'-( ��{—[G � �u..�P��� 1 rih� f Anta �►�� W�-► rs -i- �1 i W� 6 i� � � � 1�'r'�-IoOo ^ S'-"'i _'fis' �i' ll-aq �C� ,',, ��`./. C ( �%��G=� ������ !'.�,�� <�����7?�� �°���°��.�� � � j ��� �8 � �8,�� Tax Map ��_ rar��! #�� SysiEm Typ� (TGb�e 1!a) Owr�erlA�plicanf S�bdivision Address/Loca#ion Se�fPh�sz �ot # d����c d ��� State�IDlda#� . C� aci � Tee and F��t�r � • B�{�B Seaiant Riser i� a �licdble - �'anEc Ou€!�t S�ai P�mnane�i iV9arker �um� �'�nk Stat� ID/clate � � Ca acifi o 0 Waie r�o� /Sealant Riser i/I/at�r i � h$ � ��r�p Ci�ec� ValvelG�t� �lalve 0 Alarm (vi�a�le and autlo�ie) Electrica� Coar��or�ents �aie (9P�1 Approv�r� i'ump 11�ode! ��of Block Ur�def Purnp Purn� Re�oval R�pe/Gt�asn . ��Dos�a�eba.��a�a�. �����a� Seri�l Dis�ribution Pressure i�ar�� od Low Pressu�e Pipe Ap�r. Pip� M���fial and Grade Vaives � �asr»���aaosa ��n�� ��a�� irenci� V�Iidth� � �t. ,� Trer�ch D� th �- i�. T.renci� Len th o �. T���c3� Grad� � Tr�stci� S acin Roc;� De�th a�d t�ua�i Darr�s/Ste dovv�� �tc. Pres�c�re Later�l� � � HOI� SpaC��g � Hm e ize Pi e. Si��v� Turn- slP.roie�iors � ��g�a�d� �e�9��c�� From� UVe�I� � F�flm Pro¢�e�tv ian�s Surfac� V1�aiers Pu�Iic UVater� Sa� dies � Ver�icai Cut� >2 �t. � Il�later Lines �le�iicle�Trafrlc � � �a��r��nts/Ri�d�t af i!� ��e� �asesnents R��arded : I ���s�te�� � �c�d r�v. �i1;/�7'� PERSON COUNTY HEALTH DEPARTMENT SIJBSURFACE WASTEWATER SYSTEM iYIONITORING REPORT 12�15-� ll-�-D� �h �. � Date of Inspechon System Installation Date Type Tax Map Parcel # ����2 �,r�l , �/�i. Properiy Address Instructions: Check yes or no for appropriat., iteras a��d 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 pum�ing ? Inches of solids:�_ Septic tank filter cleaned ? EFFLUENT DOSING SYSTEM: Required pumps p:esent & functional ? High water alarm operating properly 7 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 ? AS Counter readings ? Drawdown rate: YES / NO REMARKS ❑ � L10 � ❑ � DISPOSAL FIELD: Evidence of effluent surfacing ? ❑ � Evidence of effluent ponding in trenches ?❑ / Surface water effectively diverted ? � / Diversions/swales properly maintained ? ❑ � Vegetative cover maintained ? �,/' � Protected from tr�c/unauthorized uses ? [vJ / Distribution devices in good coiidition "�f/ Field free of settled or low areas 7 [J / C�( � �sm �"� �C �ot4�) s?���. �'anK lo� nent ❑ N�i � t5P � o.�lPf Lh�e��Y{� -�an �i-�'r'�P r nd� ■ ■ � ❑ n��e'ji ❑ � ❑ PRESSURE DISTRIBUTION SYSTEVI: Tumups/cleanouts/valves/taps intact & accessible ? � � ❑ Pressure head properly adjusted ? �/ ❑ COMPLIANCE: Compliant Non-compliant Needs Maintenance ADI'iiTiOi�nL C,viviivi.civTS: � ■ ■ C4 �� s t� r R cCe sSr�b��