A23 122- -� �r� �� l��-�-y-- t� � ,
, ���
�
���� ��- L�,� .
� , .�.
-za
3 � � ;�
; ;'
i'� �
0
�
;i
=-�..�
o- f ���. �.�5 P L� P r r� ��' 7'� � Z
— �e-,�- e�P � � ti,�1
-- v �/ t� lo� `�' �
a,2���
� � � �D�-.
. ��'�
� �
�'� .� �ae �'-��
�' �� G L� i
-� l�C�� � S �
/ 1�.� ��� C �
I Q 1 '��a�1.•t�a�� r
�F�a�..
� �' -� �a; lS
����� t�,��f,
� � �
✓,��� ' l�'' �'c, 5 �r
�'--
.
. �` t �
Person County Health Department �
Sewage System Improvements Permit
Date:��-.�=a�'This Permit Void After3Years C� e rc� ��
Owner: SR#
Loca�on/Dircctions: , ` h L�f l7J� i
Sutxiivision N- c: �Gy�✓ Loc #�
Lo� Sizc: K T of Dwelling:
Watcr Supply: Privatc: — Public: —_ Community:
Bcdrooms: 3 Garbage Disposal `�
Bascmcnl Bascmcn[ Fixtures '
INFORMAT C T IE BY
5���,����: owncr or rcpresentativc
REPAIR: REEVALUATION:
Size of Scptic Tank: ���_ gal�ons Sizc o Pump Tank: �' �
Nitrificalion Line: � � r
Depth of Stone: 12 inches ti '
Max Depch of Trenches: ^ �
Altemativc System: Conv. Pump _� LPP Pump �
Remarks:
-------------------------
Date Well Approved: Well should be 100 ft. from any sewer sys[em
BY Sanitarian
Date Sewagc System Approved:
gy Sanitarian
C '�IFICATE OF COMPLETION
Conlractor. r tn� �Q�� � c
------------------------- �
Sewage System location, installation, and protection must meet state and local 'S
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to create' a public health hazard. Septic tank and`O
nitiification line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation.
(G.S.130 A-335F)
Location of sewage disposal sewage sys[em sketched on back.
(OVER)
Vf/lO�w�/ iV.�/l' yVVV G�i VOVV
� ����� lJ��� ���r��� � .
���t Qata .'
� : �_,�
L1�+1� Jull\L+L♦
�r�on Caun H��ifh Do��aRm�nt
�Qvirone�ant�l H�oltH 9,�ctlon
�►��.icnYtQN �o� $ERM��s
� vv�
��X �aD:k
�
i) Psnnitrequest�dby: (Owne+�fagan�lp�av�cdYsovvne�: e��1�X�e, � ,.��.,,.-
Hom� Rnon,}; 3 3�= K� 53 0 4 ��.
�ueine:s phaw.lS;.s.�.'��l i°1 � �. a,�l.'i�.. �..� �j�
,
i—=-
Zl �teca� end szdais�ss � t'��nt Sv�r, �
, <(� 1 ) + 1+ 'i � r-•► w
Ot' : �: �s lt M'�.3 L M � � c ¢.�.Si'� �l � .
�Kr.,
3) �ro�a,rty a,�ac�tpaon: ��tze: f, i T�: � j �j ��
Girscffons ba tt►e pra��,rty 1nd� �ng road nemee end numhsrs): .�O •6 �`� N4--;�1 �,+�.�
s .w.��r.+syAytir•,.
�} Praposee� IJ�r �end Slluct�Jrs GOecrtptlOP1: 9nawet ea�h ni fh9 fONoWic19 QUEstlans:
�) Propasec�, 6riu�;�g p
b) S�J�k Bui�� Modul�sr �7. Stngkr vVld� D, Aouble w�e a
�i F1uenGer c�u�r,e�: ,� ; d) »umber of ocaup�nts or pcopla te b� serv�d:
�) �Eaa+��s►� Y�9 I�, No �7 tf ya�. # af beser�9o�t tfxture�:_,,,�,_
f} Ga�99g�a Olspoa�tl: Yes 0. Ide D
g) Dtmer�a:lons ot PR�pOSea Swrsura: Wi�tis; p�p�;
��W�sge 5u�ply Typ�: F'riv�t8� (near• ot eadSifng o), Pubik Cl, Commut�t�y Q. Sprin� 0
Aro eny weUa 0 adjaWng AroRprty? Yes`�`No Q K Yes. locatian
, �
b) Ploar�• indlc.als D�alr9b0 S�smm 4yp�: (myshms can ba rsnked �re oret�r ot your �r��we�)
�,.,Con�(ofl,�l �. �uk�dif(esf Co�wnlJs�a! .3 Mt�ma�ro .c�rKtavatf�re
Oti�r ispe'�')� _._..
' CLEARL� STAKE ALt. CbRNER3 AND UR�S Of THE PR4P�RTY.
3TAKE THE CORNERS O� pLf. pROPO$ED $TRUCiJltES.
`PL�As� ATTACH 3UlZVE�f PLaT QR siT� PtAN TO THIS APPI.iCanON
i h�reby rttQ1c� a��pUCdtiaA td #�e Aengu►1 Coutrty Noalth DepartMent !Cr a 6it@ @v�lua�ort fo� the On-uite sew�ge dFiOaset SyStem tof
tha abovadesa,:b0d pnaperty. i agree thec cfie coMcrn� or mis appi�suon are we end represen� ts�e �a�dmucn faa�aea ca b�
P�� o the pn�+ertp. I un�nQ if tt�e ate (s �ttarod or fhe lRtended u8e changes, iRd p�m»t shait hecorne lnvaltd. l underatand
tttmt ea a�artt, i ret�poneible ior ldenafying and msrking pro�rty lines. co�nsrs and mak)ng 1Ae stte ac�esbtbie �Or 1ha
P�raan c�f j��nm� os�. C:au�'}i9�lth DeparVneni to coriduc! thelf eVdtu8ilo115.111pdBtstehQ tRet I flltil [espohS�bi9 tor �btir�iing the
H epa��� i! my +r��p�rt� carrtains atty v�tlands as deaignate�d by ttto Amry Co�ps �f �r►ginegrs_
_ .__._
Date
PGiO. rev.lon?19g
�O"� d9Z=60 00-6i-L�'G`
� 7l �T
�'� . , , .� ���� �b V
._.-.. � ��" � � � � � �
7.�.��u����.���;�.Il ]E-�I��.11�I�n.
Applicant:
Location:
T�x M�p � P�rc�el #
Subd'ivision � � .. . - , . �
Ph��se Sectaion Lot #
Improvement Permit
Permit Valid for ✓ Five Years No Expiration
Type of Facility: 3/3I2 resr���Q,.� New ,/Addition Water Supply
# of Occupants� # of Bedrooms 3 Projected Daily Flow 36D g.p.d.
Proposed Wastewater System: � w r�ssu �e .'
Proposed Repair: LocJ ��esscc rP �.:�oe c%} Pre �.:„o.��
Permit Conditions: �5�,��fo/ ,�,K ,fl��. /-// �/�
Owner or Legal Representative Signature:
Authorized State Agent: i
�,' � w�!/
Type �_g_
Type _ -�lI a�.
Date: "/S-ez
The issuance of this pertnit by the Health Department does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty 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 Improvement Permit is not affected
by a change in ownership of the site. This permit is in compliance with the provisions of the North Carolina Laws and Rules for
Sewage Treatment and Disposal 5ystems.
Al1t�l0Y'1ZatlOri t0 COri5tPUCt waSteWater Sy5teril (Required for Building Permit)
* See site plan and additional attachments (�).
Proposed Wastewater System: ��,.� �rrssare i�;a� Type � Wastewater Flow: ,�6c g.p.d.
New �/ Repair Expansion _
Type of Facility: 3[3i2 5;.�.a�.P �i��,-,.�, 1�s.c�e.�e�_
Basement Yes ✓No asement Fi •es Yes ,i1Vo
Wastewater System Requirements Design LTAR: .�/,� �
Tanks: Septic Tank Size: ODa gal Pump Tank Size: /o�b gal Grease Trap Size: — gal
Drainfield: Total Area: a y-oo sq ft Trench Width: �_ ft Total Length: N�8'D ft
Max. Trench Depth: � in Aggregate Depth: /o in Soil Cover: �� Trench Sepazation S" ft on center
� _ '
Specifications:
Authorized State Agent: � Date: /- f.S O�,
PermitExpiration ate: /-/�-p 7
The type of system permitted is Conventional Innovative �/ Alternative. I accept the specifications of
the permit.
Owner/Legal Representative: � Date:
Operation Permit
System Type (in accordance with Table Va)
The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Permit and Construction Authorization. Issuance of this permit implies no guarantee that the
system installed will function properly for any given time.
Authorized State Agent: Date:
PCHD rev O1/14/02
'-���,�� �,l�i�.�l���
�' � ������
�.���� � ��� ���.��
Si� S�'�' CI-�
Name �����'t T r� h Tas Ma.p #_!�� Parcel #��:�Z .
,
, SubdivYsion ��P�''� � t�v Section/Lot# � l t%
, _ - r, � - //- 0�
Authozized State Agent Date
� . �-
�
/
LOR! LANE
50' PRIVATE R/W
N82'����
LOT 8
HERI7AG� HAR80R
�
��
LOT a
NERtTAG� HARSOR
8E�lCNMARK IS TOP OF
IRr�N PIN SET - �1�Q.00'
/�/:��.,� p4y � / � �' .� `
�,
; :
. �. �
�
�
�
�
�
�
/
�
_ � ,. - 3 O '
Scale: -
.. .. ; �-'►�
: �: �
i-±Y��! _qK�
n
a
Addendum to Construction Authorization
(LPP) Low Pressure Pipe System for Ner; -�c�.a2 �,�er S� � T
Tax Map #� Pazcel�
Contents (PaQes 1-11 of 11)
Page 1 System and Component Locations — Plat Map
Page 2 LPP Design Summary
Page 3, 3a Pump Tank Detail Diagram, Pressure Manifold Diagrdm
Page 4 Control Panel Detail Diagi�n
Page 5 LPP System General Specifications
Page 6 Side Profile of LPP Trench Including Cross Section of Manifold-to Lateral Connection
Page 7 Trench with Lateral Cross Section
Page 8 Side Profile Detail of Coirect Supply Manifold-to-Lateral Connection
Page 9 Manifold Cleanout Detail
Page 10 Typical Valve and Valve Box Detail
Page 11 Typical Distribution Lateral Detail
�% °1�4,�.�
�--� 3„X � ., � �� y
���%� f �
�-�p,�ym��,-;�e�
(:�rr��'
►� "Ia���.l
3" SN�+�, �.f I�1Qh.•
�� �o✓�re�-�-
Sro�e,�ro����.7�,.;( o� Cv.+�u.�- Sa��� /�'lan: �olcl �v - �7`�rra�
�.��'lec�-reo?
LPP (Low Pressure Pipe System)
General Specifications
And Permit Conditions
2. Pressure laterals shall be sleeved in 4" corrugated nitrificarion line perforated tubing.
3. All drilled orifices shall be drilled� facing upward except for two holes 1/3 of the way from
the beginning and end of each line which shall face down.
4. Use one 90-degree bend for lateral turnups not one or two 45-degree bends. �
5. A cleanout with above ground access shall be provided on each end of 3" pressure manifold. ,
�.a�4, d o
6. A gate valve effluent supply line shall be located 2' to 5' prior to
supply line — to — manifold connection.
7. Lateral lines shall tee directly off of manifold using 3" x 3" x 1'/4" reducing tee and not by "bushing
down" with reducing fttings.
8. Elbow the manifold-to-lateral connection over an earthen dam to prevent drainback into manifold.
9. Lay geotextile fabric over trench at the gravel-backfill interface for entire length of trench
�r
10. A minimum of�' of Group II or III soil cover shall be required over entire system and extended 5'
laterally beyond all trenches. �
11. A pre-construction conference shall be scheduled with the installer and a representative of the
Environmental Health Secrion of Person County prior to beginning construction.
12. Trenches shall be iristalled on ground elevation contours. A layout of system shall be required and
. approved by the Environmental Health Section of Person County prior to installation.
13. A signed contract with a certified operator shall be required prior to issuance of Operation Permit.
�ro �u.�'vG S� � � ��eaolec�7p� � J ,//� �/ �(��,� �
�� .� T'J'11 i So1 Pd CY/'��t <�Q�l �����ff�/C-a► �ad.W
_ �
�,TCNa,/ 7Z�rr[ -K ComPae.%�cp �ar� ,%�ar�
� � p Geo 11 VQIve
�c�'le: �,6�� . W ya�ve b�X
-- j � // .
//
i t . � . . . . � � , �.. ,, . ..r , ., .,, � _ � / � R F �i e�.c9s
i � � � ` `�, • • ,. � •r � -� � ' 7 � . < - .�' � �
�.��v �,� ! �.� �l� r.���.�r i /�~� i� ��� � Y �� t�f. ��.. �r'li � r� i ^ �r�s�. •�j' 1^ �'T�'�,% � � /
� < <�t� `/� � � � t •r}, � i��ii ♦ � • .e. ,� r; \! �- L 1 � '"S' i � ^`� l\ . ..`,, . �. I �� _ ;! 1 ��`i / / i /
< � �� � - - �': %.� r, ��� � �/i/� L / • ir � �. �•� = � \��v c •;�--.% ��,,.�.-� � -��'�~'� " / / ,!
.�.� -. _� r /
�, � �r'' / <
��� ��� ►I I� I 1 I I ll - i
: ` . . � I i � 1 I ,
,�:� I( � I � � l� �
I i I
4f � � . � /
...� , .. ff
'���"� �f � .- / l r r r / r � �� r� � rr�r . + / / �
/� /� ti • ` J
VV'i ]`��CP► , '� .. , � ; r�. /Cc�t'J�' �:� �Y� 1 �< � "<< �' ��(.<<-�1 �'1'R ``-I�� yy `� iX �, .(� / � �/ /, /
CTy tC4 3 � � V � ♦ � i /� .►- �T•i aT /� �^ y`��� i - �� f�' � t��-�►� � � ��
� /�2 � i ♦� T J / ..i � `` 1� / .� ^ t 1 f �' / - t
, ` / � �,� . ^ _ - , • � / r . � � , � � % _ . ,� � , y �._ iL A ,,,C 'i �, ,�,� . � t/� •; �-'� �+. . .- /
'� � \r � i � / I /
� ' f
Vrb•ve� �ren.C`i
j-�'PLa.�era/ . .' ' /r •.. �,�� /
. (t�/,{!i d r;�'; e � Dr�►�'o.t� � �
./ . //.//
�-�'��,a��/�p� S/�e% s`'rd'�y � .,)
�aN�'-fd �c� �3 l
,
. S:�e p�'o ,'�e ,L�a.% o� lPP Ti���ti ;�tc.l�: C�' assS��ro� o�' ilair: ��c%{�-�a�er�%
�
� Cvn � ee�': on
l 1"el'l,� ��,ll �n G,q �/"G�� �DSS ,�¢GTi D�? ��� Pa �vJ
�
.____-�-
�i�/�i✓n. �ot,�2i+So)� /'��ee,T..�Xt��e '�'A,�r'.�
� .. c w � -- .�.
per�o�a'�� �p�y ,� / � � � . , ., i � ^ � . ...
l !/ � �..� � . ' � . ^ • � •',� ,• / �G+"o�►v�a� $'`��
s%�✓e� j / • _ �,, � ,~��` �, !_ •9:•w. y
- � I ; ' �n� � , �.� �
, � � �y�" ' '' ��fI/
�' f �
� � /� � � '" L` �. ,;� _• _r; f�'f +Pile, 1„ae,T�►�-f
%� ' `�—�'�� ��r` `.r ,.c.� � a � / / �
E"FiS � ` . ' � � ' � / � `
���'r%' / � � • � j ... `�'� �i ��%i/1: _ ' • .`
l��',s�ic.,�� /�� . 4� �, .� r r✓ _. • /��p �Dd�� �ren��. � ru ve f�S{arie.
�,"��. !'.� .�/,,r• ;- � � ..' + ;'' .. /
SDi� / .1 �'$�� '
'' .. . / � / / // �
/ �
_ � � ll /
0
NEMA 4X Saapl.x Coa�olPmel
x (� Dnct S�al Hoth
4" X 4" Pza�sas� Tsaated Post j E� Of Tl�e Coa�t Co�.t. Rvar
Sbped To Slmd Wataz 12" Sepuatma 24" M�t�mx�'r
� Electacal Condt�t , . . � . - , . • . • 5" Saparation
T�aeadad Gate Yalva
. .. , IImon . r �.�• .
S" Cov�r •� ' � ; Acce» Coves• � • , ' . . � 1 , : . Y�-Poztlax�d Co:ocrata Gmut
�r•' �. •, � 7 1 ` . 'r�•1 •�'' � '• '' � .'�.� �ift1C -' .
� '••- -'• • ' ' • � C� • � f'1..��„e LiiY94 �1[[L
i.• OP�C � W� Aati Siphon Hols Tisr ��, . ••Portlaxid Caxnent G:oat
Ialet F'mm Septic Tazilc Portlaad Cexscz�t Gxoat (D� g�l • �1° �� t Oatkt To Da�a
+l" SCH 40 PV�C Pipo Cbeck N n Z" SCH40PYC Pipe
�lalve � Y7oat Wim ' ;
Hi�t Watet A]arm I.owl , �
ts' s���) �
: $� Lanl- P� oa ;':"
:.
' . % �9apos Lock F7oats . �'
. �� ,• � $ole • • .•
. . % -�-� CuP �ui {-� M�° ', .
.
.,
Lrn,► I..vel -P�p o&' . �
.
� � .. _
.. .
�.. ti
. — - -- -- _
+: ' P:eca�t Coa�ete Tm]c 4• Coaesata �. Pt1NP RA?ING � .
'.; S s�3500P H1oc7c � � . �• �
� , ., . . , . . , . � , .r . � . . ` _ S : ''' Pu�op Must Be Ra t ed ?o De ! ine r
'�4� ' ' • • - ' • ' • t • •� ,�'� GalLoas Per Minute
� ' Against 25— Feet OF Tota
_ DDO GAtL�NFITl1�' TA1�TK Dynamic Head (IDH) .
��,f.� 3 ��i
P� -3a �>� - --
Profile View of Pressure Manifold for Level Site Installation
(not to scale)
� 3' tr+rste�►�
Plan View of Pressure Manifold for Level Site Installation
(not to scale)
http://www.deh.enr.state.nc.us/oww/LOSWW/manifolds.htm 12/11/2001
Simplex Controi
Panel Wit:�
Built In Alarm
��� p:e�su:z :reate� ..�'••
past a: aqc:v�.an� �
Iate: lhis is
� K 00t a viriag
� �g � "� � diaqra�t! Consnit �
�uclasure an Blectrician! "
� �ater tiqht ,
+ Dact Seal
� corrasian
�stall ? circait cesistant � .
.sconaect s�itcfl •
� pauel does �at , � � .
�Pe a dead.frcnt ?' �:a;x.:a �
�h ;annal discoanec�, �ae i�ghE � l . .
cte: d breaYer dues � ,�o���tlt s—
� caustitate a . ` ' � _
scouuect) > 1�' ta� �
. fiaish qrade�
�n�p .;npply �i:cui: � - .
.�lara Circ�it sackiaq S�-��s
�ater �ight 3aa1 �
Bydranli;. ceaeat� •
Sctiedule 48 ?YC — laraess 8z�°55 ':�ii�
Supply �- -- �-- --
: __ • -- -�--� - '
.� ; �fou�c.��. an -e-%seo� ��� �,s� �rt�ei' a�.� Zdeiv7'�
�0�' /�
C'�t�tri7��r W��'�. �n--��� �,par�e.� -� r f'Jz��; 7t�r; n� czz..�.�
a iU
`(��iC1�'� i��'t�j G'i��1.5 �'dk'�''tl: "t�1' c7d�.�' , .
.�
�
—
�'�' '
�
0
. . , ..: . .
, ' • ' � , • � ., . Ti-JRE/�O�ED G4P
' .. . '•. . � �
� ' • ✓ G'� � V L �
. . • =1ltl��t ' ' g� Su? � 7NQ:�D
.. - - . , �� b�9 ' �OU PLI IJG
. . -- � : �- -`� • . �'� •: ;� 8" R1C P� P�
. . , , � . .._
I ^ '• ' ' ..' '. :`.�.' qVEL
r� G�
1u . j •�I� � , � � ��
� ' ' �1+' o�• '
�1' I�
0
• . ' � ��� ✓ ' .
. � "_' • ' 9�`a:eta� � d, . + � ,, .. ..
_ ' , � ^'��� d0.�o d o+� t . • •
o•�•a•e
t , 3 11 PVG = ,'; ' . ' : s:'. � qo Pvc �"
. �_'_' MA}J�FOLD� • '',. SUP 7N��AD)
. . � . . • . . • • • • �.eow l �
� �1ix-A��OL�D���.��A:NO�T DETAIL
. . � . . NI'3 � .
. . • •f � .
. ',: . . .
- • . ��. ,. :
• : . • . , � :;,. ,
' . . � : � � � . . •.t. �• ��'� , . PWG
. , .�� • . , .' � ,�
. , , , � , ; : . ;', •
;•,�•,:, � r
.. � : ,, • `i �.,� � • ' �`
,. � � �'�' �''� �o� � '
�• � 6�� SUP X THREAO CCUPUNG
, � ' - • • 't • 6" �G PIPE
.� , ' . . -
. . �
. . • 9 . y, ,
. cJ: ,,p 8.� • .
. • � • ; ��' �
S��EVE � . . , , '.;� �A � � .�
. , , .e •� • •�
. •;, ,; ,: . � g .
. ..,�• ..�t•- --.�.,:..��.•»
. . , ..;•: �SC`f�O PVG 90° ELBOW
: , , ,
. . • . �. . �
. � t
• ' ' • ' �` � � CrR���L-- �
. , .,
' •' �'' .� �;' r .
• t. • :,•:
• . ' • . 4 •� � ' '
T1R 4 T1vFTFT .T1• t''�':•F. A Nlit iT i7F:TA Ti ,
�
.t
�_
:i
0
�
.. .._.. ----•--•• Zi
�.�� la �. » �
��.
. � 2J
W/ Sl,i P ou , ' '
. �:A�' , _.. , FIu15H G�.OE
� 2�
(��� �`i
3' MIU. .�''C,tAsS �25 B20�ZE ..
C�,7E VALVE �,
e �
• �� 2' MttJ.
. � /'
,
� i�O.d�'t: �ti���l/��
O
• C�USN�D 5'fOIJE
,
• o� G�.VEL '
'I'YPICAL VALV� & VALV� 130X U�'1'AII�
N'l'S � �
�_.
N
,r
' Z$
26
.-.... ..rcael CiEANOUT
• .' � .SCN.40 PV�
�'YPZ
e
DZSTRII3UTZON LA7
DETAIL
zSOMETItzC
`1 ,• �
�,��. �� ��I�� ��i�T
�---- -�-�: � � �-����
������-�.� ����.� ��.�.���.
�E� Y'ER11�IIT
I'�SE SEE AZ'�ACd�IEI) PLAN FOR WEI.L SITE LAYOU'I'
Tax Map #: %� a3 Pazcel #/�Z Township %n r�,'nr,�a�
Applicant �Yea��,'P �or�ns-�
Subdivision: l7L'V'i e�r,bor Section: LoL• 7
Location:���r; �a rr 2 �h �'-��-�-�� �
� ��... � n _ �„ � _ � O. / 1
Tv�e of Water Suvvlv: � Individual . Community Public
Rec�uireaneaits•
Site Approved by
Grouting A proved by �1 �T l,J i�n c s S� d
Well Log �(Q 3� .� 3� N� .
Well T
.Air Vent /' �
Hose Bib
Concrete Slab �
� I 0.rri d�-d f�tc� E vans cacct co.
h�d alrcad+� S���td �rou��n�
Well Dailler. �Ja� �
� D
Well Approved �y: �� Date: � S ^ �
'�°5ee Attachesl 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 founda.tion.
Oti�er
PCF�, rev. 09/07/01
.. � ����� A j �' ,r �� , (�
�� � ' � 0� �/ �
� � �.�.���
IE�.�.a-���.��.�t�.0 IF3L��.11�I�..
I
Owner:
Location:
Subdivision:
Dr�O� �D � -� 03 �
-�
C ° � uU�SlGltt�" — f�' sl <1�r S 1 �i 1 / ' ,%��, , � /, ;�3
� �� ' � _ S - /_ o -�- .
Well Lob
Ta.�c Map �� Parcel # ��,Z
Lot # `
Distance From nearest Pro e L�� Well Construction
Distance from Septic System (�Minimur� � f� 10 feeL t= � s ��-s
T o t a 1 D e p t h: �� $ yie l d: d GPM Static Water Level: �_
Water Beaning Zones: Depth d�} ft ft
-�_ ft �_ �}
Casing:
Depth: From v to �_ �}. Diameter: 6' in
Type; Galvanized— Steel � ----�--
Weight: _/� ,'I'hi�kness: � Height above Ground: � in
Drive Shoe: —�yeS No �y problems encountered while settin casin �
If "yes" give reason: � �. _Yes c�No
Grout:
Neat: Sand/Cement ✓ Concretc Gravel/Cement
Annular Space Width �_ inches Watcr in Annular Space Yes No
Method of Grout: Pumped Pressure Poured �
Materials Used: D�P� to Ft.
No. Bags Portland cement ___ Weight of 1 Bag �� po�ds
If mixture (sand, gravel, cuttings) – Ratio _� to /
ID plates: ��es _ No 4 x 4 slab vYes ' No
Drillin� Lo�
I hereby certify that the above information is correct and that this well was constructed in accordance with re ations
set forth by the Person County Heal epartirient. �
Signature of Contractor -���
� # _ b '� � �dfC �p � 3 r d ']�
PCHD rev 01116/02
�
�
�� � ���� ���
�'Ll.� ��
�, � � � •��.J � Jl �
��.�a.x-�„-„ ,� ��.��.� ����.��a
�
a�x M�p Pa�.rc�el
■
S�u,b c!!i v i�s,i o n �� '_ � �'
Ph�se Sectior� at # �
� of 6ed�roo � � �s
Applicant
�.. <!- ' . � '' ,:-..
. System .Type (In Accordance Uil'rih Table Va): q
THIS SYSTF�IA HAS BE�i1� 1NSTALLE� !N COMPLIANeE W(TH AP.PLlCABLE.NORTH
C�4ROLINA GEi�ERAL STATUTES, �RUE.ES FOR SEWAGE TREATMEiVT. AND DISPOSI�L,
AND • AL:L CONDITIONS OF � THE lMPROVEME�VT PER�fl1T AND COiVSTRUCTION
ALlTHO 7101d. - .
. � � � � � � �2"��7 �
�
Authot�zed State Agerrt � Daie �
lnstalted. By. �nn���2", �:- rr ° 5 . . Date: � %2'ZD—c�� . .
, � �� �— � • �� G{Ot,�Se � �lf' ��k0��-�. �-;
�� � • � `
. Q `�`' 1�!''1'P �'� '�`'f '�'�X'
r
�j `;Z,�w;� �
CG-�cK va l�v�e
be fun°e�, /rtite
yf s
G;�� c�,t� � � '�rt-�
� �Y l�k�e�
« y��pt
C ��'�tocc �
� i�c�'��; ���� ( � ���, r( v� 1�> �t
s�r�- a-�- �c�► � 1��f4 (
� �� � i rtit�eS . .
�
� �2 � f w� �l� ;
:
PCHL�, rev. 07I29/Q4
v1��C��7��3r i ��19 i�Y-1G����7 A ��P. !L � �
Tax Nlap #��� Parce! # ZZ . Sys�em Type (Tabi Va)
OwnerlAQplicant � � � 5ubdivision c��'�� r or
Address/LQca�ion SerJPhas� Lot # ,�
a
k
��
pct�d rev. 3I13/01
PERSON COUNTY HEALTH DEPARTMENT
SUBSUR�ACE �VASTEWATER SYSTEM NdO1�TITORING REPORT
/- -13
Date of Inspection
%-1Z�-��'�' ,�
System Installation Date Type
-b� L�- 'I .
Property Address
�3 12Z
Tax Map Pazcel #
Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and
cominents. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate
by "N" and explain. Nate that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are to be carri�d out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks 7
Tank risers accessible, free of
infiltcation and surface water diverted ?
Septic tank needs pumping ?
�nches of solids:
Septic tank filter cleaned 7
FFFLUENT DOSING SYSTBM:
Required pumps present & functional ?
High water alarm operating properly ?
Floats, valves, etc. in good condition ?
Control panel & components in good
condition ?
Effiuent free of excess solids 7 r�
Inches of sblids(pump/�ose tank):�
Elapsed time readings 7�rl� a
Counter readings ? �� �
Drawdown rate: a E' r
YES / NO
o�❑
a % � N
❑ � ❑ _
i
� ■
i: ■
►: ■
DISPOSAL FIELD:
Evidence of effiuent scrfacing ? ❑
Evidence of effluent ponding in trenches 7❑
Surface water effectivety cLv:rt�d ?
Di��ersioas/swales properly maiatained 7
Vegetative cover maintained ?
Protected from trafiic/unauthurized uses ?
Distribution devices in good coadition 7
Field free of settted or low areas ?
/�
/ ❑
/ ❑
/ ❑
�o
/ ❑
PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible ? ❑ � �
Pressnre head properly adjusted ? '� / ❑
COMPLIANCE:
Compliant
Non-compliant
Needs Mainten3nce
�L CUNI�iv7S: IC�
Ck.-��r�-'4- So S �
REMARKS
� ��� �
�� ac��s$; 6 �
'� lii0 (o�L OLl �� �� Y��� rf� •
ppS�S,�,�Q ,.�,� � ► 5 ���-.
a�C�-�,: �,s`` (r�;y� �9dD�. -` `J
� �
.
� D►-q;,,.�Pf9Q � ��a� C��, c,C� fi�.
� �(( ta��a�s �.lus(�.e�.�.
� /� 'a q ( i V A +�-� a � �s �Atv�
�e�.,, �k.e�,. �ll s��r( �,�����1
-C
���
��,.pssu.-e 1.�..�� Se�- � ���'��.
�
❑ .
❑
'H.�t�Q�� ''�(i`�ll',�
�G�� (av� � S
C
�3 - �zZ
�
DAVID BRANTLEY � SONS
WASTEWATER TREATMENT INSPECTION REPORT
SYSTEM OWNER: OPERATOR: Admin,Admin
Jordan, Charles & C nthia CERTIFICATION: •
ADDRESS PIN#
206 Travis Lane TAX REC:
Gibsonville,NC 27249
SYSTEM OPERATOR:
DAVID BRANTLEY & SONS
DATE OF THIS INSPECTION: 11/28/2017
DATE OF LAST INSPECTION: 6/6/2017
Y N REMARKS
FACILITY:
Type, size and sewage flow in accordance with permit X
TANKAGE:
Risers accessible, surface water diverted? X
Risers structurall sound, waterti ht? X
Sanita tee in ood condition? Effluent filters cleaned? � X
Slud e depth/a earance , level acce table? Xx Buried noriser
Grease Trap: X
EFFLUENT DOSING SYSTEM:
Slud e de th/ap earance , effluent a ears clear? 0
Required um s present, o eratin , and c clin ro erl ? X �
Hi h-water alarm present and o eratin ro erl ? X
Vent/floats/pipe/valves/disconnects in ood workin condition? X
Control anel/electrical com onents in ood condition? X
GROUND ABSORPTION FIELDS: �
No evidence of effluent surfacin /reachin surface waters? X
Minimal pondin in subsurface trenches? X
Surface water diverted arounc! fields, no depressions? X
Line cover/ve etation adequate/maintained as needed? X
Protected from traffic, destructive uses? X
Distribution devices accessible? X
Distribution devices in ood condition, workin ro erl ? X
Repair area ro erl reserved, maintained? X
Turn-u s/cleanouts/valves intact and accessible? X
No effluent standin in lower laterals? X
Laterals free of excess solids, flushed as needed? X
Diversion Ditch/Berm in ood condition? X -
COMMENTS:
MALFUNCTIONING
NEEDS MAINTENANCE
STRUCTURELY NON COMPLIANT
O erator: David Brantle & Sons,lnc.
Date this Date last No. of days:
11 /28/2017 6/6/2017 175
Pump #1 Inches Min GPI GPM Feet Head Events this: 500
11.25 3 21 78.75 4 Events last: 467
% Efficiency of delive 78.75 NaN % of design Diff: 33
ETM this: 40.69
ETM last: 39.00
ETM diff: 1.69 101.4 78.75 5.24999999 175 45.63
x60=Min xGPM GALS Da s GaIs/Da
CC This CC Last CC Diff NaN
Notes:
O erator: David Brantle 8 Sons,lnc.
Date this Date last No. of days:
11 /28/2017 6/6/2017 175
Pump #2 Inches Min GPI GPM Feet Head Events this:
25 NaN Events last:
% Efficiency of delive NaN NaN % of design Diff: NaN
ETM this
ETM last:
ETM diff: NaN 0 NaN 0 175 0
x60=Min xGPM GALS Da s GaIsIDa
CC This CC Last CC Diff NaN
Notes: