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) The District Health Department
CASWELL:- CHATHAM - LEE - PERSON COUNTIES
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VI/ater�Supply and Sewage Disposal
IMPROVEMENTS PERM_I,T No.
'lti4.1 r , �,J '}.
F�te 1
Owner: _ ��� � � : , t�` `�- � � + �
Location: .�� r ' •
Contractor: —
Water Supply:
n
_ __ ! ; ; ; �, �;.: - /
Sewage Disposal Facilities: No. jbedrooms � Dishwasher, DRsposal,
washing" machine, other automatic appliances
Size of tank: � ��,? � � � Nitrification line: ^�=.; /
, j � '%�-v � �� 7
Other disposal facility: r �T
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
5eptic tank and nitrification line MUST BE INSPECTED AND AP-
PROVEII BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE;FNS�p, LLATION IS COV-
ERED AND PUT INTO USE. ,% ;`/ �-�,
� � (� / ; L' / �
� ��,�(�����1�.,�' I` ��'ti'��, �;:
Date approved: Signed �`"�✓
Sanitarian
Well:
Sewage Disposal:
By:
Counter-
signed
(Owner or his representative)
Certiiicate of Comp 'on ��`1 I ��� �
Date Approved: � ` y: '��� ✓ ~
anitarian
(OVER)
Location of well and sewage disposal facilities sketched on back.
�TQTE: Mal�e sk`c��c� of installation showing lot size and shape, location of house, septic tanks, privies, water �.�
d..
�„ supplies, etc. N te special problems existing on lot. Wnite in measurements in order that installations may be located �
at later date. q� location of water supplies on adjacent lots. ;�
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= P�rson County Health Departm�
� � � Weil Permit
Date: ���,Thi Pennit Voi After 3 ears jr
Owner: �JP , � %�lh� uY�`l.'t" SR#
Location/Directions:
Subdivision Name:
Drilling Contractor.
I.oc
:nt �
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�—�
#1_1_j 1 __
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Distance &om Nearest Property Line L5' �? /4a: �s Distance from Source of
Polludon Od �
Total Depth: Ft Yield: �,�GPM Stadc Water Level ��� F� �
Water Bearing Zones: Depth ��_ F� FG Ft F�
Casing: Depth: From � to FG Diameter. 6� Inches
TYPE: Steel � Galvanized Steel �
ff Steel, does owner approve: Yes No
WeighG �_ Thic�s: Height Above Ground: T2� Inches
Drive Shce: Yes No
Were Problems Encountered in Setting the Casing? Yes No �
If "yes" give mas��r : ' b
GrouG Type: Neat Sand/Cement Concrete �
Annular Space Width 3 Inches
Water in Atutular Space: Yes No ✓
Method: Pumpeci , Pressure Poured t�
Depth: From �= to F�
Mta�t�e�rials Used: No. Bags'Portland Cement �_ Weight of 1 bag
7 Y lbs.
If mixture (sand, gravel, cuttings) - Ratio: .Z to �__
ID Plates: Yes ✓ _ . No ►�
4 x 4 slab Yes ✓ No �
I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEALTH DEPARTMENT.
��..� i1i, i/ 1.�. �-�� /
Date Issued
Sanitarians Signature Date Completed
Sketch well location on reverse side.
`� NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
�, supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
� � at later date. Note location of water supplies on adjacent lots.
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Su,bd'ivi�s�ior�i �� ' •' `' �
h�s�e Sect�ion'Lot r
Improvement Permit
�ersmit Valid %r � �ve 3leaa�s No ��iration
Type of Facility: �� �� New Addition _
# of Occupants # of Bedrooms Projected Daily Flow
Proposed Wastewater System: �
Proposed Repair: � ,� (Z� �.
Conditions:
Owner or Legal Representa.tive Si
Authorized State Agent:
�Vater S�pply
g.p.d.
Type: _
1�ate•
Date: — `-�D
The issuance of this permit by t�Health Department in does not guarantes the issuance of other permits. It is the responsibility of the
a}�plicant/property owner to in sure tha# all Person County Planning and Zoning and Building Inspections requirements are met This
�lmprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affec#ed by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Itules for Sewage Trenrment and 1)isposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the
Environmeutal Health Specialist warrants that the septic tank system wi11 continue to function satisfactonly in the future or'that
the water supply will remain�potable. � y
Authorization to �onstruct Wastewater System (Required for Building Permit)
* See site plan and additional anachments (_�. �z �0�
P YS YP
cu�
Pro osed Wastewater S tem: C�� �2�/I' �_ Wastewater Flow ���Q �g.p.d.
New Repair� Expansion 2 Soil LTAR: ► 25 g,p.dJ ft 2
Type of Facility: 7� �- Basement _ Yes � No
'�astewatea� Syst�m l�equireffients
T�nk Size: Septic 'Tank: `P x• gai Pnmp Tank: � gal Grease arap: gal
�rainfield: Total Area: �� sq ft Total Length � ft Ma�ffinm Trench Depth IZ ��� in
'Trench Width � ft 11�ini'mnm Soil Cover. _-� in Minimnm Trench Separation: � ft �� C�
�istribation: �istrii tion �oat Serial Distribntion � Pressnre Manifold
Cnariiiaatinnc_ lF/ /'4C1'.X(.lf'tf7�'�fr.ri� �Or � �'1' C,(/�C�l "`� !/W�S�'�/�D'C+ �C-� �,�'�'7p
Authorized Sta.te°Agent:
Permit Exu:
The type of system permitted is
permit.
�wne�/.�,egal �epresentaiive:
Date: 7 �l S` `�
Conventional DC Accepted Alternative. I accept the specifications of the
Date:
PCHD rev. 11/10/OS
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SI'TE PLAN
Name � ��" `V � `/- Taz Map #� Parcel # �2 �
subd' � o rrJo►� section/Lo �
,
uthorized State Ageat Date �
Systrm compoaeatv xpasmt sppr�u�msae canmrra aalp. 7Tie oaau�c�must9sg t6e syatrm pnar m begmnLog tlie ins�na`oa m
inautr dintPmPergrlde ia msiar�iaed
`pr-esS� � = Y.�l��� � d--��SS
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IE�.-ri�� �e�a�.li ]HI�.�m.Il�e]la. Owner. � �V'""'�
Tax Map: � Parcel #: D : � `�
I,ine Tap Tap (Scli) Tap �'!o� Y�ine I,ength �'1ow / foot
# Diameter(in) { m) -'. ft)
1 Z � O � 5' � �
2 l _p �^ �.- �vw � �,p� �_
3 2 O �. Z� �✓ . d S`l
4 °�'��
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5 �q �;
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Z; ,�
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8
9 �
10 �
�� ft vf 'ne x 65 . per 100 ft=� ��d���` ; 100 ��' �gal
75°lo x� ga1= ��� gal per dose 2�per minute (gpm) _]Rlo�v I�ate
Friction Head �
Loss: f� ft per 100 ft jf ��ply line x�� S�ft of snpply. line =10U = • y�ft
,� ft x 1 2 ft of fricrion head . �(-Q v�
Z � � �'-e�.P .
Manifold Size: �" F'orce Main Size: " PVC �
Totai Dynamic �[ead =��ft of Elevation head��ft of Pressure head + s'�ft of p,,-p x'.
Fricdon Head = �g�TDFi �p `
Putnp Requirement: '�Z GPM @�P �7. ft of Head . �
Drawdown:. 1�(7 � per dose � 21 gal per inch =�� inch dra.wdown per dose
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--�-�-�-.. �_..-..-._�_.._,_n---�-�._.-�-�---.._�-<-�-�-.,_�-�-.. :-.
II II II fil .�...,.........,�..�. ;...........
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7�i��hs� .
Iwi1Qa��
9m� � '�" s �
iiold Sizr / � Taps
M�x Na Taps off one
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4
9
y� 40+ 21 � 12 1
. . . . - . ' Fio�v er Ta
Size iLlruerial Flow G?�!
l.�.'� Sched SO �.S
. �s „ Sc}red 40 �._
�i, °• �ched 80 1 � 1
'!, ' Sciieri 10 I:..i
� `����,�� ���� ��
��Y � � ����
I���-a�-��.���¢.�.]L IHL��.Il�I6�
NEMA 4X Simplex Contml Panel .
4" X d" Pressasv Traated Post_�.,j ;
. Sloped To Shed Water 12• Sap�ratiox
� Electrical Conduit =
6" Covas • ' � Acce» Cover• � •• ' � ;+ � .1_ , �
. � ' � r • � !
.•. � , � r' - ��, : ,,t , � � .�
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, �,, Openin= Filled With . Anti Sipkon Hola' `
Inlot Fzom Saptic Tutk Portlaxid Cemant Gxonit �� g��
A" SCH 40 PVC Pipa � ' • ���
� , � Valve �
Higk Water Alarm LavYl
(6" Separation�
' Hi�t Leval- Pump On -.-"��
• � • �t +�Vapo:Lock
' �, �% Hola
• • ' � —l�Dravvdnvm (Up H�11)
� ' �
: Law Laval -Pump Ofi' --��'
,� �;. :� . ' • .
. '•. � ' Preca�t Cozucxete Taak
' • .; Material Strenbth }35(
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T��x [Vl��,�� P,�rrc�l # � ♦
^ � � � � '- � �
Suhciivi•sion ��� �,.,
Fh��se S�+ct+.ion Lmt #
Ihut Saal Both
End� Of Tlu Coz�dnit
--� 24" Mininum
, . .�-•
Tiireaded Gate Valve ;
-- .. i
z�p ca�a
Tia� 1
Rop�
4" Conctata
�SI�_ Block
. . .; , . : . :� ,
Concz�ete Rusx
6" Sapuati.on
. , :• , � • �� ��,�.r"�—�.
:4,",r.-Po�tLndConcrete Grout •
� j: biutu • - : .
. ry� � .
. 'op.� �ivaa w�eh
upply � :•' portland Gsiunt Crrout
rii1Q L � 5 .
Outkt To Datnbuiion
2" SG$40PYC Pip.
P7oat Wire� ' �
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i
F1oat� . �;
�..R.emovable �•�.
F1oat T:ea , ,
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� ��GAI,LON FU1V.� TA1�TK
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Aoalicatlon Dabe: v � � �v �
Amount Pald• �
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TaxM �: ��
rcal #• �
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- - . � � �7'�'��" � �
�GC�.vB.s-.m��,--�-� oss�m71. 7C—�.e�a.71.�.�.
APPL1CA710N fOR SEiZVICES . •
��� ��-���,.�,�,
Home R�Addt�on)
5150.00f�00.�0
Pemui I�evis�n Feo -
. � .
1) Pemtit requested bY: , toHmerFaee�ttprns�ve o�►ne�: �'.�.� =��/ ��
Home Phone: • • Address;/ ' � �
8usiness Phone: . . ' '
• 2) Name aed addQ+ess of i:u[r�ea! owne�: ,���ra '4f r-,.�ivP
3) -property Deswiption: Lnt size: Tawnshtp: � Subd'nrision: � �-+ Lat ���
Directlons io the ProP�Y ilnduding road names and numbers): •
4} pr+oposed Use and Str�u�un escriptlon: answar of the f�itouving questions: �
'a}� Prnao�d _, �e �Ty�e �t�s�: ��� -r�� � � widtn: � �a n�tn: �d
b) Number C�F Bedro� . 2 Number of acca�pants or peopie to be �,� .
'. C) �Basemeri� Yes�No ._ Will be plumbing ln #h� basement? _ _
. d) 6atrba8e aisPosai: lc`�s . No� . �.
5) Waiec SW�P�Y'�5/P�: Prh►afie �(new _ w e�dstin��, Pubiic_,J, Commun�Y.�, SW'N9
. � A►re any wells on adla�9 ProPe�y? Yes No _ ti yes, please (nd(r.�te appm�imate locatiori on the
.siba pian. • . �
� Does yaur property c�t�in pc�eviousiy tdentifled jw9sdlc#ional wetiands? Yea ido �
PLEASE N THE FOLLOWINC: "
➢ A PtAT OF THE PRO1��EiiTY OR SiTE PLAN MUST HE 3UBN!'fTED 1N�fH THIS API�.lCATlON.
➢ PROPEiiTY UNES AND CORNEi2S MUST BE CLEARLY MARKED. -,.
➢ THE.PROPOSED LOCATiOId OF ALL STRUCTURES MUST 8E STAiV� OR FiAGGED. �
9 THE 31TE B�US'fi �E READILY ACCESSIBLE FaR AN Ei/ALUA7i�iN BY THE HENL.TH DEPAR'[AAENT
BTAFf. ' .'
I hereby make appllcatJon.to �#ha Person Caur�iy Heaith Department for a sit�e e�ralua�on for the an-sibe sQwaSe disposa!
system for the above-desctibed proQeriy. 1 agree-that the corrter�ts of this appiic�ion ara true and represent ihe maxirnum
facii'�ies to be piac�d on the property. I understand ifi the siie is aitered ar the intended use ct�anges, the permii shaU
harr�ma invalG�
r �//
ri
Date
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J.L� �.�'�1�- � �l1 �*�*-n aG �n. ��.11. J.L � �.�.J1.�JI�
Applicant < `((,
Locaiion: � � �
. . � �
a
�
a�x M a�p � F a,rc-ei ` /
S�u;bci!ivi�s,iom �
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Fhase S�ction Lot �
� o�f Bedn�oo � � s
. � o ' a ��
, . . �er�t��r� F��"rm �� . .
. Sysiem .Type (ln Accordance 1JV'rIfi Tafaie Va): �i �
THtS SYSTE3V1 HA►S BEE311 INSTALLEi� 11� COMPLIAN�E WtTH AP.PLICABLE . MORTH
C�ROLtNA GEi�E€iAL STATUTES, RUtES FOR SEifltAGE TREATMENT_ AND DISPOSAL,
AND - ALL CONDITiONS OF ' THE lMPROVEMEIVT PERfltI1.T APID CDiVSTRUCTION
AllTHOR T10N. - .
. l�r�' �-�C �v�� � � l �'' .�� d �
Authorized St�ate Agerrt � Date -
lnstalletl. By: ��` (l�l� . Date: � �(� "�� =v �P . .
. . . � W � ��M
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C�O � `��� PCHD, rev. 07/2Q/�4
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+� ��-�c -� � �c ��s����-�o� �����s� ��� �� a �
Tax Ma # !/ ► . � � Parce! # Sys�em Type (Table Va)
�
QwnerlApplicant � � � 5ubdivision
Address/Loca�ion SecfPhas� Lot # '
pci�d rev. 3I'i 3/01
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
- $- f D -ZS-Dl� � q � /Z �
Date of Inspection System Installation Date Type�J Tax Map Parcel #
�� Lo�� Ln .
Property Address
Instructions: Check yes or no for appropriate items and 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 aze to be carried out.
INSPECTION RESULTS
COLLECTION SYSTEM:
Evidence of leaks ?
Tank risers accessible, free of
infiltration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids:
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Required pumps present & functional ?
High water alarm operating properly ?
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 7
Counter readings ?
Drawdown rate:
YES / NO
❑ � ❑
❑ � ❑
❑ � ❑
■ ■
�I ■
l�I ■
� ■
7� �
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DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑ /
Evidence of effluent ponding in trenches ?❑ /
Surface water effectively diverted ? Q/ /
Diversions/swales properly maintained ? ❑ /
Vegetative cover maintained ? [� /
Protected from traffic/unauthorized uses ? � /
Distribution devices in good condition ? /
Field free of settled or low areas ? �/
REMARKS
)U8� aCC�S� b j�
�
o N/�
❑
O r
� �"e�u rZ. nna� i T��c�
PRESSURE DISTRIBUTION SYSTEM:
Tumups/cleanouts/valves/taps intact & �
accessible ? ❑ /
Pressure head properly adjusted ? ❑ /❑���} �(� C�QaV101A�
COMPLIANCE: /
Compliant jf
Non-compliant ❑
Needs Maintenance ❑
be �aw �ra�2?
EHS _7