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Person County Heaith Department �
Sewage System Improvements Permit
Date:.���o-a-T'his Permit Void After3Yeazs ���� d�
Owner: SR#
Location/Dircctions: " h ��O T`'
Subdivision Name: .� �ur�✓ Lot #�.—
Lot Size: W Ty of Dwelling: .
Watcr Supply: Privatc: Public: Community:
Bedrooms: 3 Garbage Disposal
�, Basement Basement Fixtures � �
� INFORMA��������tT�IE BY
' Sani[arian: � owncr or rcprescntativc
REPAIR: REEVALUATION:
--------------------------
Size of Septic Tank: ��_ gallons Si � of Pump Tank: �
Nitri�cauon Line: �
Depth of Stone: 12 inches
Max Depch of Trenches: -
Altemativc Systcm: Conv. Pump LPP Pump �
Remarks:
�
Date Well Approved: Well should be 100 ft� from any sewer system
BY Sanitarian
Date Sewage System Approved:
gy Sanitarian
�_CERTIFICATE OF COMPLETION
Contractor. �i � ��l,c �
------------------------- �,
Sewage System location, installation, and protection must meet state and local '�
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained �
by owner in such manner as not to czeate a public health hazard. Septic tank and`d
nitrification line must be inspected and approved by a member of the Person County �
Health Department before any portion of the installation is covered and put into use. If
the site plans or intendeci use change this pcmut is subject to revocation.
(G.S. 130 A-335F) : � ,.:'
Location of sewage disposal sewage system sketched on back. '
(OVER)
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Applicant:
Location:
Ta�x N1�a� �� f'arcei � t
S•uhellivis,ioii •if ��„ _ ,<<����
Ph���se Sectioi� Lot � � ,
Improvement I'ermit
Permit Valid for ►�F' e Years _ No Egpiration
Type of Facility: Usf,C New ✓Addition Water Supply �,�_
# of Occupants # of Bedrooms � Projected Daily Flow Z d g.p.d. �
Proposed Wastew�ter System: � �� ,.��� . Type:
Proposed Repair: /�'� � .u.i Type:
�
Owner or Legal Representative
Authorized State Agent: �
-ir�o 6-17- 0
Date:
Date: p
Tb.e issuance of this permit by the Health Departinen�in does not guarantee the issuance of other permits. 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 revocahon if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construet �V�stewater System �Required for Building Permit)
ti'
* See site plan and additional attachments (_).
Proposed Wastewater System: ,��� Type � Wastewater Flow .p.d.
New ✓ Repair E ansion _ Soil LTAR: �/� g.p.d./ ft
Type of Facility: v Basement Yes _ No
,
' � Rzastewater System Requirements
� Tank Size; Septic iank: �p0 gal Pump Tank: /60� gal Grease Trap: gal
Drainfield: Tota1 Area: � sq ft Total Length �j.�p ft Mazimum Trench Depth � in
j� Treneh Width ''��: l ft Minimum Soil Cover: 1��P in Minimum Trench Sepazation: S ft
\
Distribution: Distribution Box Serial Distribution X Pressure anifold
.� , , , , . . , / �iU%�►//,�G� ���i��/1� �%
Authorized State Agent:
Permit Expiration
The type of system permitted is
the pernut.
Owner/Legal Representative�
Cor�ventional
�
Date•
�i Alternative. I accept the specifications of
�-I�� .
PCHD7/30/2002
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Ta$ Map # ��Z� Parcel #�
Section/Lot# Q
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Dat
System components represent approximate contours only. The contractor must flag the
system prior to be1;innin� the installation to insure that �ro�er�rade is maintained�
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Low Pressure Pipe System
Property/ Person County
Tax Map: D Z Pazcel:��_
Design Specifications
Design flow: Z D d
LTAR: •! gpd/ft2
Tota1 area: /!pD b ft2
Lineaz feet: � ft
Trench width: ��' `� ,
Gravel depth: /Z "
��'1iR� ���
Number of laterals: � �
Lateral length: / /� � � /o 0
Lateral diameter: 1%Z' (sch 40) Z 95�
Orfice size: 3/16" 3 � ,
Orfices per lateral: `�" V
Orfice spacing: �
�!
• Laterals sleeved in 4" corrugated drain line.
• Holes drilled in top of laterals except for second hole from both ends (drilled in
bottom to allow for drainage).
Supply line diameter: Z�� (sch 40)
Supply line length: !�p ft.
Manifold diameter: ' (sch 40)
Design flow: m
Esti.mated TDH: � ft.
Pump run time: 3•!p min.
Dosing volume: < O al.
Tank drawdown: �inches
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Pump Requirement : �o��� �� ( or equivalent)
Notes:
phone 336.597.1790
fax 336.597.7808
20-B Court Street, Roxboro, NC 27573
Jun 11 04 07:56a
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PLEASE SEE A.'I"TACHEI) PI.A1V FOR WEI.L SITE LAXOUT
Tax Map #: � 3 Parcel # 1� 7Cownship C-u � u� u%�
Applicant: � ra,� k�a 1� c� e�J
Subdivision:
T�e of Water Su��l�
�e�uirea�ents•
� IndiPidual
Site Approved by �� �1-�--c7 t
Grouting Approved bp � �-�-J�
Well Log �c_�s ti-�.-J�
Well T '�
Air Vent �-6�i-�/
Hose Bib �
Concrete Slab C-�S
Well Driller.
Secrion• I.ot• �
Community Public
��
33
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Well Approved ��:�` � I�ate:_
'�5ee AttacPied Site Sketch'�
Wells must be 10 feet from propertp lines.
Wells must be 100 feet from sepric systems.
Wells must be at least 25 feet from anp building foundation.
O�er conditions:
�
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PC�-ID, rev. 09/07/01
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I��a�-i s ao ns.a�a��3 �.m,1 I�ZL r�.m.�vt7�:
l�"36 �`�
Owner: �
Location. �
Subdivision,
...,,.;u 4:o Lr�.;...�;:nnr-.a�� tinn'.:ii 3J459??BOJ �. �
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C �►t�.F��n� NzflnE� � � )
�;�.�� Uri:���, �
��ll �a�
Tax ��ap �3 Parcei # _�1�/
L�t # ��
�Well Construction
� Distance From nearest Property Line (?�iinimum 10 feet) `�
Distance from Septic System (Min.imum 60 feet) +l—�
Total Depth; ft Yield: � GPM Static Water Leve�: � fi
,:� Water Bearin� Degth,�� ft ft ft ft
; Cxsing:
` Depth: From (7 to L� $. Diamctsr: ��_ in
Type: Galvanized Steel �
Weight: �_ Thickness: __ f� Hcight above Gzound: � in
Drive Shoe: Yes Na Any problems encouutered while setting casmg? Yes � No
If "yes" give reason:
Grout:
Neat: 5and/Ce�ent ✓Concrete GraveUCement
Annular Space Widtf� �_ inches Water in Annular Space Yes `��o
�Iethod of Grout: Pumped - Pressure Poured. �"Depth to _
Matei-ials L'sec�:
No. Bags Portland cement Weight of 1 Bag ��' Po�unds
If mixture {s�n� cdygravel, cuttings) – Ratio `� tc��
ID plstes: _� es _ h'o 4:e 4 siab ____ es _ No
Drilling L�g Locutiun Drav�ing
Ft.
From To Formsation
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{ �
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I hereby certify that the above information is correct and that this well was constrc:cted in accordance� ��th regulations
set forth by the Pr,:son County Health epartment.
Sagnature of C�ntractor T� rD ;# �3 ,� I�ste _�o
P f-ID rev 011i6i02
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��n.�n�^��n.n��n-a��.� ����.���n
Applicant:
Location:
T�x M��p i � F�rc�el #
Subdivi�sion .�E; �s .�� .� ,�
Phase Sect�ion Lot #
Operation Permit
�
Sysfem Type (In Accordance With Table Va): _��t
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.
�
- ; - 7 �D
A thorized State Age Date
Installed By: '1/, �-�GtJ�� Date: �P 7� �
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: N\ N
:
PCHD, rev. 07/29/02
Tau Map #:
Zoning:
Subdivision:
Applicant:
Location:
Parcel #:
Township:
Section: Lot:
Operation Permit
1. LOCATION AND SEPARATION DISTANCES
A) System meets .1950 setback requirements
B) Distance from system to any wells
C) Distance from septic tank to foundation _
D) Distance from system to property lines _
2. SEPTIC TANK
A) Visually inspect the exterior walls and top of the tank
B) Visually inspect the interior walls, baffle, tee, filter, riser, lids, air vent,
bottom, and water tight outlet
C) Date of tank manufacture
- D) Tank serial number
E) Liquid capacity of tank gallons
3. SUPPLY LINE TO TRENCHES
A) Grade (1/8 inch per foot minimum)
B) Material supply line is constructed from
C) Diameter
D) Length
E) Distance from tank to drainfield/distribution device
4. DISTRIBUTION DEVICE(S)
A) Type
B) Is Device water tight
C) Distance from the distribution device(s) to the trenches
D) Is the device on a level foundation
E) Does the device perform according to its design specifications
F) Record the inlet and outlet elevations
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5. NITRIFICATION FIELD
A) Trench depth �'� inches
B) Trench width / 7� inches
C) Distance between trenches _ ?S �
D) Number of trenches �✓
E) Length(s) of trenches /b `
F) Aggregate depth /Z inches
G) Aggregate material and size �"'✓-7 v��o�%
H) Record septic tank outlet elevation
I) Trench grade (< 1/4" per 10')
J) Step downs
a. Minimum of 2' of undisturbed earth
b. Proper rise over step down
c. Solid pipe used
d. Elevations of step downs (Record elevations and show on as built)
See "as built" plan on attached sheet.
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PCHD, rev. 07/29/02
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE Vi�ASTEWATER SYSTEM NdO1VITORING REPORT
%2-2a-l3 �"�3'�0 `f 'l
�
Date of Inspection System Installation Date Type ax Map Parcel #
� [ � L.Q rr !� �Yit �
Property Address
Instructions: Check yes or no for appropriate items and explzin inspace 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. Not� that this monitoring form is not totally incleesive for all systems. All maintenance
and monitoring items specified in the permit are to be carrisd out.
INSPECTION RESULTS
C�LLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumpin� ?
Inches of solids: <�`
Septic tank filter cleaned ?
►:/ ■
1�FFLUENT DOSING SYSTFM:
Required pumps present & functional ?
High water alarm operating properly 7
Floats, valves, etc. in good c�ndition 7
Control panel & components in good
condition 7
Efftuent free of excess solids ? ir
Inches of sblids(pump/�ose t�): G 3
Elapsed time readings ? q
Counter readings ?
Drawdown rate: i
DISPOSAL FIEI�D:
Evidence of effiuent surfacing ? ❑
Evidence of effluent ponding in trenches 7❑
Surface w�ater �ffective2y divertsd ?
Di���rsions/sw3lss propsrly mai.n±ained 7
Vegetative cover maintained ?
Frotected from trafiiic/unauthurizzd uses ?
Distribution devices in good cottdition 7
Field free of settled or Iow areas ?
! ❑
i ❑
/ ❑
/
/
/
/
/
/
/
/
�
/�
►.
■
■
■
■
■
■
PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact &
accessible 7 � � ❑
Pressure head properly adjusted ? / ❑
COMPLIANCE:
Compliant
Non-compliant
Needs hlaintena.nce
Ai)DiTioNtii, coNM"Eiv i S:
►'
■
■
REMARKS
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INSPECTION OF ENGINEERED SUBSURFACE Vf�STEWATER SYSTEM
Department
_ �('9 i
Location
}''2�t IJLC�-11J �. i�
OwnedAgent
S�m�
Operator
GE !-1 � Q �30
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Name of Fstablishment
LO �2.� �. � uc-
Type of Establishment
; U E, �YYIr� 2 �
Address .
2
Permit/Project No.
�6 �-P� Z-F�-
Design Flow
��34-y�-c 4
Phone
Phone
Yes No REMARKS
1. ESTABLISHMENT:
Type, size, and sewage flow in accordance with permit? ...................... �❑
2. COLLECTION SYSTEM:
No evidence of leaks into or out from sewer lines/manholes? ............... �❑
_ ..
Free of blockages/solids buildup in lines or manholes? ........................ ❑
3. TANKAGE (Grease Traps/Lift StarionslSeptic/Dosing Tanks):
Tan::;isers accessible a;,d surface water diverced? ................................ ❑
Tanks and access manholes structurally sound, watertight? .................. ❑
Sanitary tee(s) in good working condition? ........................................... ❑ �^
Tanks pumped, cleaned out as needed? .......................•••....................... �❑ T� Li C�1� GL�,,�lU E�j
4. RAW SEWAGE LIFT' STATTON (if present):
Required pumps present, operating, and cycling properly? .......:........... ❑❑
H�gh-water alarm present and operating properly? ................................ ❑❑
FloatsJpipe/vaives/disconnects in good working condition? ................. ❑❑
Control panel enclosure/components in good condition? ...................... ❑❑
5. EFFLUENT DOSING SYSTEM: •
Effluent appears clear, free of excess solids? ............................:............ (f� ❑
PLTMP SYSTEMS:
Required pumps present, operating, and cyc(ing properly? ................... �] ❑
High-water alarm present and operating properly? ................................ ��
FloatsJpipe/valves/disconnects in good working condirion? .................
Control panel enclosureJcomponents in good condition? ...................... ❑
Elapsed time readings:
SIPHON SYSTEMS:
No evidence of overflow or siphon leakage? ......................................... ❑❑
Siphon(s) appear to be working/alternating properly? ........................... ❑❑ �
Bells and vents free of debris and in good condition? ........................... ❑❑
6. GROUND ABSORPTION FIELDS:
No evidence of effluent surfacing/reaching surface waters? .................. �❑
Minimal ponding in subsurface trenches? ............................................. ❑❑ N� �O N l�i 1J(�'
Surface water being effectively diverted away? ..................................... ❑
Diversions/ditches/swales/tile drains properly maintained? .................. ❑
Line cover/vegetation adequate/maintained as needed? ........................ ❑
Protected from traffic, destructive uses? ................................................ ❑
Distriburion devices in good condition, working properly? .................. ❑
Repair area properly reserved, maintained? ........................................... �❑
LOW-PRESSURE PIPE DRAIN FIELDS: � ❑
Turnups/cleanouts/valves intact and accessible? ...................................
No effluent standing in lower laterals? .................................................. ❑
�.aterals free of excess solids, cleaned out as needed? ........................... ❑
Presswe head is properly adjusted? .............................••••-•••••••--•........... ❑��SkTc}� ��, LV-�-���L.s
DVERALL COND�ON AND OPERATION OF SYSTEM: '�(, G� LL�Q1i� D VEiLPrLj_. ('� I,_J7 l'RO �,�} ��
D P�-���� , lfit_4. '�o QT�tv ►vS o t= Sy SrC-�v� C� w� �P c-.� h ��. ('T2� �n�� h��R��o _
'C 1 r� 7 Q n ti0 �2L�I In� .A- �� i 1� � N�� _
SUMMARY OF IMPROVEMENTS NEEDED:
Improvement Repair Within (Days
fi9aN� �2z-�u��+�
�
DATE: h I �z I �
DENR 3702 (Revised 3/98)
IV C:...tl/�.w.....���C�..�:....ID...:.....1'1/04\
— nvr.r —
G�r� � " � � � � AGENT
Division of Environmental Health