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A23 180z 1�erson County Health Department Sewage System Improvements Permit Date: - �7 This Permit Void After3 Years �� Owner. SR# � �Z2 Location/Directions: Subdivision Name: � Lot # Lot Size: •�'; �;��r Type of Dwelling: . Water Supply: Private: �� Public: Community: Bedrooms: ��,;� Garbage Disposal Basement Basement Fixtures INFORMATri�l t Q�R'�jIF�D BY owner or representauve REpAIR: �" ' ' REEVALUATION: Size of Septic Tank: _�� gallons Size f mp Tank: _ d� Nitrificauon Line: � � Depth of Stone: 12 inches - �� S'm -- �-��5� > Max Depth of Trenches: Altemative System: Conv. Pump LPP Pamp Remarks: --------------------------- Date Well Approveci: Well should be 100 f� from any sewer system BY Sanitarian Date Sewage System Approved: By Sanitarian � CERTIFTCATE OF COMPLETION Contractor. ------------------------- � Sewage System location, installation, and protection must meet state and local � regulations. Septic tank shouid be pumped out every 3 to 5 yeazs and shall be maintained ►��- by owner in such manner as not to create a public health hazazd. Septic tank and't3 nitrificadon 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) i.ocation of sewage disposal sewage sys[em sketched on back. (OVER) 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. (1 �„ ' � Aqpfication Date:. Arn�unt Paid: / , Receipt #• L� Person Countv Health Department Environmentai Health Section APPLICATION-FOR SERVICES Tax Maa #: � � � Parcel #: � ` °�' � D d 1) Permit requested by: (OwneNaaentlprospective owner):_ Home Phone: Address: Business Phone: .3s6 � S97 :S'S% 2) Name and address of current owner. �ir"� ��v � 3) Property Description: �ot size: ,s,I� Township: L�� Directions to the property (Indudin� road names and number�'j 4) Proposed Use and Structure escriptton: answer each of the following questions: a) Proposed 0, F�dstin b) Stick Built-B; Nfodular �, Single wde 0, Double �de ❑ c) Number of Bedrooms: �, d) Number of occupants or people to be served: e) Basement: Yes �, No � If yes, # of basement fixtures: fl Garbage Disposal: Yes ❑, No ❑ g) Dimensions of Proposed Structure: Wdth: Depth: 5) Water Supply Type: Private 0(new ❑ or existing �), Public �, Community 0, Spring ❑ Are any wells on adjoining property? Yes � No ❑ If yes, location 6) Please Indicate Desired System Type: (systems can be ranked in order of your preference) �cnventional _Modified Conventional _ Altemative _innovative Other (specifyj: �oT /3�/� o.��f'�.;v� � CLEARLY STAKE ALL CORNERS AND LINES OF THE PROPERTY. STAKE THE CORNERS OF ALL PROPOSED STRUCTURES. PLEASE ATTACH SURVEY PLAT OR SITE PLAN TO THIS APPLICATION I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum faalities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that as applicant, I am responsible for identifying and marking property lines, comers and making the site accessible for the personnel of the Person Courrty Health Department to conduct their evaluations. I understand that I am responsible for notiiying the Health a ent if property con ins any wetiands as desi nated by the Artny Corps of Engineers. � ^ wn or Leg epr tive Date PCHD. ��. �a�yss . ��ouNrv ca�F4y . �� y * . # * * � q \ P'i.�� O�Y i� ■ o��HCOUN��G�. Decernber 1, 2000 Mr. C. R Pointer P.O. Box 796 Roxboro, NC 27573 _PERSON COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH PROGRAM 20-B Court Street " Roxboro, North Carolina 27573 . (336) 597-1790 Re: Application for Improvement Permit for wastev�ater system for property owned by Jim Stovail at Oak Point S/D lot 14 • Person County Health Department File: Tax Map #A23, Parcel #100 Dear Mr_ Pointer: The Person Cow�ty Heatth Departmeut, Environmentai Health Division on October Z, 2000 evaluated the abov� referenced property at the site designated on the plat/site plan t6at accompanied your improvement permit . application. According to your applica.tion the site is to serve a three bedroom residence with a design wastewater flaw of 360 gallons per day. The evaluation was done in accordance with the laws and rules goveming wastewater systean.s in North Carolina General Statute 130A-333 and related statutes and T'rtle 15A, Subchapter 18A, of North � Carolina Administrative Code; Itule .1900 and related rules. Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Itules .1940 through .1948, the evaluation indicated that the si#e is IINSUITABLE for a ground absorption sewage system. Therefore, your request for an improvemem pennit is DENlED. The site is unsuitable based on the following: 1, Soil depths to saprolite unsuitable (Rule .1943). 2 Topography and Landscape Position (Rule.1940) 3. Available Space (Rule.1945) These severe soil or site limitations could cause premature system fa�nre, leading to the discharge of untreated sewage on the ground surface, in surFace waters, directly into ground water or inside your structure. The ste evaluation included consideration of possble site modifications, and modified, umovative or alternative syst�ms. However, the Health Departmern has detennined that none of the above options will overcome the severe conditions on tlus site. A poss�ble option might be a system designed to dispose of sewage to another area. of suitahle soil or off-site to additional property. For the reasons set out above, the property is cunentty classified IJNSUITABLE, and an imQrovement permit shall not be issued for this site in accordance with Rule .19480. However, the site classified as UNSUITABLE may be classified as PROVISIONALLY SUITABI.E if written documentation is provided that meets the requirements ofRule .1948(d). A copy oftlus rule is eaclosed. You may hire a consultant to assisst you if you wish to try to develop a plan under which your site could be reciassified as P�iOVLSIONALLY SUITr�BI.�. You have a right to an informal review of this decision. You may request an informal review by the soil scientist or environmental health supervisor at the locai health department. You may also request an informal review by the N.C. Department of Em�ironment and Natural Resources regionat soil specialist. A request for an infarmal review must be made in wiiting to the local health department. You also have a right to a formal appeal of tivs decision. To putsue a formal appeal, you must file a petition from a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a perition fomi, you may write the Office of Administrative Hearings or call the office at (919) 733- 0926. The petition for a contested case hearing must be filed in accordance with the provision ofNorth Carolina. - General Stawtes 140A 24 and 150B-23 and aIl other applicable provisions of Chapter 150B. N.C. General Statue 130A 335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you m�st file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF T� DATE OF THIS LETTER. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a fornial appeal wit6in 30 da.ys will not iIIterfere with any inforn�al review that you might request. Do not wait for the outcome of any inform�l review if you wish to file a formal appeaL If you file a perition for a contested case hearing with the Office of A,dministrative Hearings, yau are required by law (N.C. General Stawte 150B-23) to send a copy of your petition to the Nort6 Carolina Department of Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Departmern of Environment and Natural Resources, 1601 Mail Service Ceater, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to your local health departmem. Sending a copy of your petition to the local health department will NOT satisfy the legal requiremem in N.C. General Statute 150B-23 that you send a copy to the Office of Genera] Counsel, NCDEI�IlZ - � , You may call or write the Person County Enviroamental Health Departmem if you need any additianal infonnation or assistance. � Sincerely, � � � �S 1Vrchael E. Cash, RS. Emironmental Health Program Specialist Environmental Health Division Person County Health Departmern Cc: Janet Clayton, Environmental Health Suparvisor Marc Kohlman, Heaith Director .-� , , . _ _ 2,c� 2 V��"� . . /n ��( o�� -, J Applicati�n Date: f? � l I '�� 'j�`0�'� �e��`' )� � `� Amount E�aid• 6. V 0 `/��\1`�� `�� Recaipt #: • 2 7. 3l Q_ G�✓ � �� Tax Maa #: � �� Parcel �• � . � � 3 �—��5� ��.� �� . 0� � � ��,.�.�-�� ZC.T� �" � (006� E �a . � `a� 36 � APPLICATION FOR SE32VECES :::::-.: -._::.: . .::..:..::: •-;:.;::;:. . :::::;:,._ - �.....�.. ... . ...... . �.;.. ,,...�........ � .....:.. :.:::i.v:�.i.:i'�:fi_:::ii.i�:.:..::i'i:.:i�:i..::.�:.: :i:i:i'�i..'="'F:��:...;.;....... .....�..�.-..._ ��.........i•.... .a�f:�.:'v,�l: .....'dF.,ai.,: -. :.T^L��:: :::T..-:>..: � ^"'` �'� C'ii'.: :�..... . _ �..: �. _ .. .� � �Mf_';<: i:..iii"}C:i: ::::ii�: i":'. �'� ... "'S��P17IG2S,;�2QUESEECI .'i.;r? .+4..t�... . .. 4.Y::. ii.�+..�i.L^•: .. ::. ..-1,K ., —! : '. . ... :_ .. . ... .....>(v. ... .". ...:. .. . . . '.. ... . ..a.. .. . . . . ❑ Improvements Permit (Recarcled Lot) -$200.00 0 Well Permit (NewlReplacement) -$225.00 ❑ Imprnvements Permit -$150.00 Canstruction Authar¢ation for Septic Systems- {Mobile Home ReplacementlAdditlon) $150.00/$200.00 � RepaidReplaca Existing IF THE INFORMATION 1N THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRE_CT. FALSIFIED, CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SH�►LL BECOME INVALID. . � 1) Permit requested by: (Owner/agent/prospective owner): �� d��QC= Home Phone: 336 -�q�-5�v��3 � Address: � 5 t v�• Business Phone: 753 t�- Z3 y-o ZO'7 0„ or v � �1 r/5 3 2) fVame and address of.current owner. S�� 0.�(�� d S i n Ci. . o NC � 3) Properly Description: Lot size: �,�� Township: �Unn'' �Fia�t�l Subdivision: �G�k �D�i � Lot # I Directions to the properiy (fncluding road names and numbe�): . � , � 4) Proposed Use and Structure Description: answer each of the following questions: a) Proposed � Existing , Type of Structure: }-�'DUSQ Width: � Depth: b) Number of Bedrooms: � Number of occupants or people�to be served: c) Basement: Yes , No �% Will there be plumbing in the basement? N//� d) Ga�bage Disposal: Yes . No ✓ . 5) Water Suppiy Type: Private �(new V or existing�, Pu lic . Community , Spring _ _ Are any wells on adjoining property? Yes_ No �if yes, please indicate a�proximate (ocation on the � site plan. • . . 6) Does your property contain previously identified jurisdictionaf wetlands? Yes_ No � PLEi4SE NOTE THE F�LLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPUCATION. ➢� PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ' � ➢ THE PROPOSED LOCATI�N OF ALL STRUCTURES MUST BE STAKED OR FLAGGED: ➢ THE SITE MUST BE READlLY ACCESSIBLE FOR AiV EVALUATION BY THE HEALTH DEPARTMEAIT STAFF. � I hereby make appiication to the Person County Health Department for a site ev.aluation for the on-site sewage disposal system for.the above-described properiy. 1 agree that the contents�of this appiication are true and represent the maximum faciiifies to be placed on the property. i understand if the site is altered or the intended use changes; ttie peRnit shail becom valid. � �� n � �� , l � )d,�(�� _ � . ' '�� or Legal Representative Date . . PCND, rev. O6l27102 � ��1��.�� .�' � � �l�l 1L 11 � I��.-�.a-�� ,�,.Ii 7E-��.1I�]]� Applicant: S Location: �%1, � c _' � � T��x �li�� i � ' -:t r c :. � ' : ♦ S�u:hclivi�s�i�ia /• + F i��_�,e='S e�c ti;o io � L.o t� �j'g�V�ffi�II$ $��$ Permtt Valid for r�T'' ive Y�ars. I�Tq �pira9�on �� y �'�k�-e Type of Facility: S';,,�, /,� �'�<� ,'/h � l�s� �� New ✓t�ddition _ ��ter �upply �va �� # of Occupants �- 6 # of B ooms ,3 Pmjected Daily Flow 36 d, g.p.d. � Proposed WastewAtter System: . � . Type: ��,�b �- . Propos�ed Repair: c��-�. � � � '. � • � TYpe�?"�'�' . Pennit Owner or Legal Representative Signature: •� '�� Date: Authorized. State Agent: � ��S ' Date: 2- j7— o�- The issuance of thia permit by the Heaith Department in does not guarantee the issu$nca of other peYmita. It is the responsibility of the apPlicant/property owner to in sure thst all Person County P�lanning and• Zoning and Building Inspections requirements are me� This Improvement Permlt ie subject to revacation ef the $ite plan, plat or the intended use changes. The Improveanant Permit is not af%cted by a'change in owneratup of the property. �his permit veas issued 3n compliance with the provisions of the North Carolina `Zaws and gule�, for Sewr{g.e. Treatment and Disnosal Svstems' (15A NC�C. �8A .1900). Neither Person County nor the Environmentai Health Speciatist warrants that the sepiic tank 9ystem will continue to func#1on satisfactorlly in the future or that the water supply will �emain potable. � � �Antho�rizaiion to Con��ue�'�asteveater Systeaii (�te�uired �oa� ��aing �ernuit) . * See site plan and additional attachments (��. Proposed Wastewater System: e�� y �•'- e� Wastewater Flow 3�.p.d. New ✓ Repair Egpansion So� I� T A I t: • 3 g-p. d./ ft 2 Type of Eaciliiy: 3f�/� �':..s/.e .��.• �.�s/'��_� � Basement Yes e/No �astewat�r Sy�tem Reqairements Siae: Septic Ta�k: BOD gal ,. �p Taaa.k: . fOpo g�l � Grease Trap: �" gal field: Total Area: �v sq ft Total I,engt� �---0 _ ft 1VI�muffi Treneii l�eptla ��n eh W�dth 3�t 1l�iini�� Sofl Cower: �,6 ixb Minimum Tr�nch Sepazation: 9 ft : I3istributioa Box Seri�l Dishribution _ . r- �- �- � v v, /. �� Pressure Manifold Aaathor�aed State Agen$: ^ �/��ZC� � Date: � O/ O f� Pernut Expiration Date: �_ j�7 — o� . � The type of system permitted is ✓Conventional Innovative � � the permit. ' f O�ner/�e�� }�rese�tatave: . .� . Alternative. I accept the specifications of Date: PCHD7/30/2402 . , �--,��,S�f ��.�� = � � � �� I��-�a�-��.7�-r-,. ��.11 I£ 3C�.�.11-�1�. SITE PLAN Name 7��'v'e ��a-��z_ _ Tax Map #.�� Parcel #/B� Subdivision ' Section/Lot# / , ` Tf -� � uthorized State Agent Date , . ---- — �— — — � ._ ��:<<, _ ._.. ._... . . � , . .. ..... � : OAK POINE `DRI`�E �0' F��N �� . � . --------- � , -. .. . � --------��.—_.___:_�, -- — — — — , . . � . — .T.: ._. _:._._ ..,_ ...� ._. — --� - — — -- _ __. _ ., . . , - : � . ..432•.36 : . 438.93 . . . . - i `��6 i�� / `� %. �% /��R�� . �' , . �3 �441:Q9 . � ' �35: ..- . :. �3�3 / . , Df�AIN=FtELD FOR� / � LOT 13 � � �39 `~ A ,42,$ � � ��ENT�RLINE� . � '. ,, ��2'2E34 Q 37 �GREs .: �. / / . 0�" �RA��H�,,.: .: . ...�. �---�45.35 � STEVE W. WALL�ACE .& , � �40 � : ��:,��3 53 � ' �SHEILIA �G 1NALLACE .��'.. • : / . � / � � � D.B. 410-382 - . 42��04 :. . E42 I E�}1 :� �� o . , , . E30. 445.37 � � 4:27:4�.-.: ' �30.12' . 4:44:9 / tc� .s� �;/ , Q`-' \ E.31� CENTERLINE OF. � : � . / c� <t.- E29 � �� .4��:9� � '/ � � . �0` aRAIN . �ASEMENT� � �� o �- r�v . �o ' _ , �'�', l' ;�oa , . . FQR. . I�OT 1 � � � / �� . .• �,� ' ��2 ��e� Mh' . . � 425,7�- � 0� . ,� . °�.. ��' . � I I / �3.:$8��'� M . / ,; � � �: E�3 � ... , . �. � � � E�S D(�AIN=FIELD /�. 428;.4�.0' . _ , , ; FOR LC�T 14 ( �2� � , � I . � � � � . �2,a 2 ��429, 29' . : , .- . , . I ( � 421.01 , , � ` • E26 . . � ,. � . �. . . . . . ,.:, � .;-�2� ;.�r 2� ��.. .� . . �2 ' �. , _. . I . 421 04: ��, G'ONrR �y . -, -=--42525`. . - � . . .� �� I . .. CONTROL : ��h'NE� � , CENTERLINE: OF � .. � � COf�NER /:. . .L3 � , : � � , '. . �,4. / .. . �� 20� [�RAlN EASEMENT � . . , ,/,.,'., . �� I � . � ,h�' , 438.5� . � , , �OR LOTS 13 �c 1 � ,.. I f L4 �'� `�� . . : ' . I �- � � �• � � ` � � / � �:��, _ . I � � I �. � �. . :. . .�s . : . . � .s�r�v� w:: rN�,��ac� � , . � . � �� I � �: � . l /. �:_17 �; L6 . . SfiEILIA :G,. WAI�I.ACE , I . : � / � �� L16 , E23. :" . ' 439.71' � . �: � � . � , . ,B. 410-.38 / I � .. S� . � . / � E�2� � , .�. � . % . / , � L15 429.41' :;:��, . , � l � , �2�422,7��.' T� ' ..,� � j � I � _ � , . � ,. � � . . �. I � % � `� , . . � ,�`' �.� � L14 i ., 4�3:,5� . . �,*. � . . . E20. . . . . �,. ;�.. . CENTEfZLINE UF � � 6Q � � . . �, � � :� 10' QRAIN. � L13 : : , . � . �_ O�,'� . , , � ✓.� . EASEMEN�f � ��`�'4�1,98' . 9� �' �. f ' FOR LOT 14 E19 � " .� . , � . r ,l. � . .. Q,��1F- ; - . , ....t.r, .PRQPOSED �, . ,� ) LAKE 422.22'� . �� . . . ti�USE� . ��, v �I 1_12 m � . . . . � C1 �P �, � � ` . � . . � �_� . . L9 L10 . . . ii__..-�-------.-__._. __.___- � LOT 13 j _....,_ . L�11 S,�j, . ' : . .. L10 � ' . / . S� � S. ,. 2.4�� ACRES � / /. ``''�_ / � A-.48. .- . 0,��, . _""_.,r �� . , �1.:9 sr� �'�►. `c / '�� . . . �r l� . % .�.�`� o�`�' � .�s�- � L1 � �i�..� / �SO; � OPOSED : ?� � T .. . � ... p• �' � PR S�� . HOUSE 0� � � . f �� O . � - 2t� S � A , r � - LpT i �; �. ��;;�_ � l �l� . � � • , . � L01 14 \ .. � � `�� IOUS�. SI7E`\�� U.93 ACRE �c; .� , f M. OAKLEY JfZ. � . `�''� � � � � � . `�- ��j; . � . ELEVATIONS 26�-368 � "��, . L8 � ti'. � �� . . Scale: i.: . i . C2 . :: :. � • i , . .-' . . . � . .. . �;' . _�--.',.-� � �---- ,., ,�„� � • Ranii �� LEMGTH +_ _TANGEfJT__.._-T---- �. � �� `_, . f - -�- c� � ��T�� Z��rn_-�n��s�-rr,rn �arn.�.�.Il. ��n,ll��n: Name � Q -e a Subdivision D' " � � Authorized Sta.te Agent Tax Map #�� Parcel #_%�� Section/Lot# /� f - �-o i - o�- _ Date 1 ��rt �,��,f , �: - � i . s''/"`� _ _ „� " _�—'� __'�.�� -' . �. ��- � ; t� � o c� � �,�.%n �� '%�r' Q`°-� �c Nu,vt�e�' �/�� 7- ._ � �ia..� ��t�s � .sh�u�� .�: e �G�.J — — ._.- � / d -%-`5��.� 'to a✓c ; � T � I /SC�� P �C,� r��-' - - �-�� : �r� ��'.I� � ', n �- - �.�- ;5��_.�'�� g.� f�/ : 4 . i ,�� Dr�' n �tYl�f . �� : �,,�; .� � �,.� e2� 1� �„ � . .�%j��i`?r�''.?o ;"✓ �y-' '�'> ai:S . . � s��.��c S %^ � ., � f„ � ;�,, r ,/ � �� ,�,�1"�.�' -l�'r.,�u_j�� ,�•d .��r:-��;;�,` �� = .., _ � Glk-ECL'v� ��, 4��Io� �,r=•'�..r %or�c. ' �✓ ' ^ � /, 2• �J7 SuP2 ,�'a,";'t �"'�.. ��,. 7`"��.;;r ��!�'ri>3' G�:!�'� qr� 7J�o' '�/"a.h --u/' ; a..-_•..._ ;n�ol'-�i�. _ � v � ~ - � � �^ 3..�v�lo,,� l�d�:--��_� crs :,�..��y� 1-�'�� ar� �'z;�.��,�v�a�e�aa/lau��,�-- ---` �— �,� , �f , � • ;� ,,,� , . �%L/P*! �+/�iLY 7fl ,'_,�'ii��d/j� 1i1�:r,..r:��t.�;?�'. 1 � r. � � ,� � � r� ri�� %�� ryS�cc,�/ �tf�'GL+YI �/'CtJy, ��lii,.:..>�,�s„3�rJd" u�S Op�- Cts �, :d�`% 7 'Sa�'1 � -2- 4u.Tf�. j�4r��J�'iit,�;.�.%^�.�rrt� / : ` � , }+ � � • 7 // }� * �� A / � ��) § ��ira J'� ) %��C.(Jn.� �'vtvP%V�� y:��r� i7 ��si1 �� • ��4cili.d��:Y.'��/ ��'�`U � � r+ .+'' t ` 'r�/+ ,7� � t J � Y'9%��:�I� � ��%�df�si `�i'!.� ':?��° e:�"�/' r 4�� ,si :,1:; ✓ ��.. �'✓�'y'�%s/i r�r �,,,• e 1 t ,� � ! . � � ' %� ,p � � fl ' � ��" ��.c� �'r ,�,`''-d�t �i1�.�/w� �" :e.�� f' �. 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' . : . � • x • � ��Tt1C • . _ . . . j�. �' � r =, , � , � � : • ti�• _ . . � � Openimc Pi11ea With �p �0� . . � (�Pa�g F�led With ' •' r.• �ti Siplvan Hole q'i� SnII81P Portlaad Cuaer►t Groat Inlat Fmxa Septic Tank ostknd Canunt Crioat �� I'�Q ••' Oat�et To Dit�butiori �l" SCH 40 PP� Pipa "� Z" SCS40P9C Pipe C�mrJc �T Q+�*� �� Float V�uas � � High Wat•s Alaxxn Lav�l "• r ,' (6° Sepmimn) . . Hi�kt I.ewl - Pnmp Oa i• .. .% �VapozLock . Floafs .: ' �• - �� 'pr� Hole • �„iteawvable ' '•. iIIF x�1 . . •; � ,. , ��T�.o , ,. Low Lavel-PamII Off � _ �P • .:• s ' • �: ' Pxecast Concrcte Ta�nk 4" Cozxxets �� PU�iP [{ATING � . :•; MateaalS r3500PSI B11ack � � . ..i; . , � ,,. , . , , . . . : � . . � Pump Must Be Rated To Deliver �'�; • • .. • - .f • :` t � �S Gallons Per Hinute � ' Against y-s Feet Of Tota I6�0 G�Lt�NFITli�' TArTK Dynamic Head (rDH) . Fitting to ailow for connecting Aluminum or steel clear pressure monitoring tube shoebox-type covers with handles (leave tube in bottom of vault} (150 Ibs. each, max.) Support straps or`—�'--� �-�'� �� i� ��, �� leve) manifold installation supports Cravel pit for irrternal drain discharge C�f'� � s ��t� U��ves /z'qu;r.e� as v�v��Dr.Js -� �� 3��f � SCl�'�!-� 7v t" i�� %VD Ie :.�2. � 1,6 -�zs r/12cry�, �� - zs � ,� / / /� �� 2 „Sc%ol`�/� gQ �U� � �c.r�%o.� a�-��p,p /oC'a-7�i�its Ca) % ' :sG.�e�w� �50 �V� �� Profile �iew of Pressure Manifold for Sloping Site Installation (not to scale) Tsp - direct ilinad or saddle �� (if tspped wrthmsle sdaptor, tr� Presstu+e hesd c.i�eck fhuh wrth mside a�a]�i �` vault Obsexv�i� port (tee wrtii exta�si� brau�rt to grade; wiRh reR�ovsble c�) l 1 1 1 � to disu►l�s �— supply Ix�dernalvsouh draat Tiue�imi bsll vslve �Su V9�YE W�l tW0 a15CmIIiCCt lmire�c� 1 � 3" sopply lmes st mai. 1.O�e slope , Plan View of Pressure Manifold for Sloping Site Installation (not to scale) http://www.deh.enr.state.nc.us/oww/LOSWW/manifolds.htm 2/19/2003 ��1 �.25Si1:: :I2�t�4 -••••p �7QS�'. J: ?Q4:P3i2Ila`. �' KS� �% . ••� • 3nclasnre �at�c tfgtrt � + �stall ? circnit corrasian resistaat o .scannecL s�itc$ • � panel does �at � � �re a dead frcnt :" ..•.:..a � d �� aannal disconaec�. �s: '•-�� ote: A hreaker does �:�c�: . t canstitate a � . \ scauuect) > 1�' to . fiaish qrade� nAap .;applp cl:cal" � 91ar� Ciresit . � iater ;ight 5ea1 • '�� qdranli,: ceaeet� • _ _ -� Sc6edale �0 ?FC Snpply �-- — — �— �iqqyback pl.uq and Receptacle --� � . � 4z4 pressare treated ,� post ar eqniralent Ng�IA �g �a�lasute �atet tight . . . + � catro9}0n cesiataat - . . � Z' ainisa� Gas liqht Conduit � >li' to fiaisli qrade . paap snpplq circ¢it alara ecntrol � � �ater 4ig�t Seal Hydranlic Ce�ent Haraess &zcess Cords — � Schedule 49.?YC • Sapplq. Simple� Control Panel With Built In Alarm �ate: fhis is nat a �iring diaqraa! Cansnit an Blecirician! "� Duct Seal � : % ;ackiaq S �=3�s � �araess 8s�ess �:a:�s � i 4tceptacle znst�be aaLor :ated Lav-Qaltaye alara �' conaectiaa Dact Sea2 •'6e a�arz aas� he aonnr.2 i� :5e i*ai;ia3 liviag area ar �he dae'_liag iaot in t�e cra8i ;pace qaraqe a: nude: a 3o6ile hone; ;�e paeei aust be aad;5le and zisi5le tu spstza :sers �� Lockisg straps ��,�� ..�� _.: � � � ��-�- �° n��n�r�an.,.-,r„ ��n.�.st.� ��.��n. WELL 1'ERMIT I'�.F�SE SEE A'�"7CACHEI) I'LAN FOR WELL SITE LAYOU'I' Tax Map #: � Pazcel # / �� Township Applicant- .S�dP, a��' p Subdivision:. ��/Z 7`d� � 7" Section• Lot• �� I.ocation• .��Ct�r ��►..�tr 4f� .U/'/l�'�� Ty�e of Water Sgant�lv: v IndiPidual Community Public Reguire�ents• Site Approved bp 5 I-�� Grouting A prov d b �' 1� v��-��.�%� Well Log , �_ �7 �5- Well T ' � ` .Air Vent � 4 ' �5 �� Hose Bib C� Conctete Slab CS �'� - � - �� ..: � � Well Approved B Date: `� � Z S` �S '�See Attached Site Sketch'� Wells must be 10 feet from property lines. Wells must be 100 feet from septic systexns. Wells must be at least 25 feet kom any building foundation. Other conditions: PCHI.�, rev. 09J07/Ol � t �� , r� 2� �� .,.�- �� I��.� �� d� � �--- —,— ��-�-� o ��.��, �..�„ ��.� ��.�.�. ��- o o � , � Applicar� s�. � �� - Location: � C � �f � � Opera�io� IPerrni� . � � � System Type (in Accordanc� With'Table Va): '� TIi1S SYSTEiN HAS BE�iV INSTALLED (N COMPtlANC� YVfTH APPLICABLE NORTH CAROL•lNA GEAIERAL STATUTES, RULES FOk� SEWAGE.TRF�►TdAE�lT AND DISPOSAt, : AND� ALL C�IdDIT10HlS ,.OF THE IMPROVEiNEAIT PERMiT AIVD,. C�NS�FtUCTiOId . � ��r}to : .. . . � .. .. . � . . . . �� S� . � - ��{-�'Z5 -os . ... . . � . . . � � Autfiorized tate Age t .. - • � Date � � . � tnstailed 6y. J • �--Q,W`�~ 5 . Date• � ,^ ` �l."'� T . - . sct� �a � �� .d�s �. . . �. ��. �,� � ��z �j��.. . � .. . .. . -. .- � � �,� ��Y ��,��, ur Sa� � y�S�i �� f ��t �,�� 1 � �� U��s w� � e�.�e�f- � `G � � {��'' c�� t i � � /� � S�TiC 7' K lIVS��ii�N C�IE��.lST (T�e 99 - l� . Ta: MaQ # � �arcz! # �I'fl � System Type (fatile Va) � OwnerlApplicant• Su�divisian � Address/Lnration SeclPhase Lot # pcftd rev. 3113/0'1 o�u� oo � g �-��,5� I[�I��$:�� o � �_ � � Cf :c��:T�T��_ �iaa�na-��a.�can��ca��.�: �'��s.��n.' U�41151� LNUWI�I°.l I ��v Grout Log 0��: �j �� e(..,��C-e Tax Map�a3 Parcel #� Location: Subdivision: �,rL 4� o � ►ti, _ Lot # ! Well Constrnction Distance From nearest Property Line (Minimum 10 feet) �� Distance from Se tic System (Minimum 60 feet) /Ud Total Depth: � ft Yield: � GPM Static Water Level: _�) J� ft Water Beanrig Zoncs: Depth D ft ft/�JJ� ft ft Casing: Q Depth: From Type: Galvanized Steel Weight: Drive Shoe: ./ Yes If "yes" give reason: _ Grout: to � d� ft. Diameter: �_ in f Thiclrness:1� Height above Ground: 1�_ in No Any problems encountered while setting casing? Yes �No � Neat: Sand/Cement Concrete GraveUCement . Annular Space Width inches Water in Annulaz Space Yes No Method of Grout: Pumped Pressure Poured-� Depth U. to v�`� _ Ft. Materials Used: - No. Bags Portland cement L,�, Weight of 1 Bag .5� Pounds If mixture (sand, gravel, cu ' gs) - Ratio Z to �_ ID plates: f Yes _ No 4 x 4 slab � Yes _ No Liner: Depth: Date Installed: Grout: Drilling Log Installed by: � .��o,. Location Drawing From To Formation d � � � � �� v 7 � C�rlv�rt- 0 � � d � � � o � o � =� � lY��+�s i�� l ( � I hereby certify that the above inforniarion is conect and that this well was constructed in accordance with regulations set forth by the Person County Hea epartment. n� � Signature of Con actor% �� ID#� Date �-a7 os " Pump InstaIlment Pump Installation Contractor: ��i/�D�T (�v-e- il State Registration Number: l�G �/ Pump Depth: ��D ft tatic Water Level: � ft ` Pump Make & Model• p (�� — � Pump Size and Rating: ,/� hp � 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 tt�isx-gsort�as- r'ded to the well owner. . Pump Installer ' _(J-� Date: o� 7 O.5`� PCI3D rev O1/27/04 PERSON COUNTY AEALTH DEPARTMENT SUBSURFACE W.AS1`�WATER S"YSTEM MONTTORING REPORT ?« c s-i�- a� ��6 f�a3 rso o Insgecdon System Installatio� Daie 'I�pe Tax Map ParceI # Cs�� .. SEr� , t•�t a'1 ProuertY Address Instrucriaus: Check yes or no for appropriate items aad explain in space pravided for remarks and commeats. If aa item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N' and explain. Note that this rnonitoring form is not totaliy inclusive for all systems. All maintenance and monitoring items specified in tiie germit are to be carried out. INSPECTION RESULTS COLLECTTON SYSTEM: Evidence of lcaks ? Tanlc risus accessible, frec of infil�ation aad svrface water diverted ? Septic tanlc nads pwngin8 ? Inch�es of solids: L� 3eptic tank filier cleaned ? EFFLUENT DOSING SYSTEM: Requi�i aumps �res�t & funciiona! 7 High rraur alarm operating properly ? Floats, vaEves, etc. in good condition ? Control paaei & components in gaod condition ? EfAuent free of excess solids ? Inchrs of soiids(pump/dose tank): L3 Elapsed time readings 7 i1 fL Counter readings ? T� Drawdown rate: �M� NO ❑ � � � ❑ ❑ � � ►� ■ � �� i�� ■ � ■ .� ■ t�+ ■ DISPOSAL FIELD: Evidence of e8luent surfacing ? ❑ Evid�ence of effluent ponding in trenches ?❑ SurPace waler ef%cdvciy diverEed ? � Diversioas/su�ales propuly ma'sntained ? �egct�tive cover eiaiatained ? Protccted froa� traffec/unauthorized uses ? Dutriburiou elevices in good condition ? Field free of settled or low azeas ? / / / / / / / / . �_ t: ■ ►'= ■ ■ ■ PRESSURE DIST�UTION SYSTEM: Turnups/cl�nouts/valvesitaps intact & accessible ? � / ❑ Pressure head properIy adjusted ? / ❑ COh�'LIANCE: Comgliant Non-compliant Needs Maintenance i� ■ ,T REMARKS �I9 `' �.� � Zi't�. "Zt 6�. �. S� �� 0 5�.= Z r,�\ = 5a.5 G� � ,� MQ.�v�s�� AcN�.'� � Ar�� 'rrres So sAPv��•S � ��'� O ri �S �Qs�w . .ai� S'�tAY ��A is �r�sEt[ 1t+�v�tl F%NotYt�tfJ br „�ti�'c, vt�w�c Aa-�� • r;.uuiTiviv.ii.. Cvivii+%i.cNTS. {1�E4 ��E� '�-C'�i, C�fitl. �F �1.t►�iS �' ��.+E�-5 ' �we�r�crL� �•s��ct, CCQPFSL. S�f� �►n��,`t �ot� �Cr 5�'pRkssspt� � ovC��}v�,,� SYS�.t-� A�P''t�A,(1-S �� cr1 �oa0 ��a�� Application Date: � ` � 7 "/ � Amount Paid: Receipt #: - -_____ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Aome Replacement or Building Addition ' $150.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ��.sf I��T � �.�� lEaa�aa�oTM* � �aa�.Il ]E��mIl�lin. �lication for Services Services Re uested Construction �uthorization ee is de end�nt on the ty e of Permit Revisi�n T� Map: _ Parcel#: - pair of Eauting Septic System Applicatioa: No Chazge/ CA $150.00 or $300.00 1) AppUcant Information: Name: N � a�a � �-�-a Address: ��n ft� � � I-6 n� p �c� .�757 Z 2) Name and address of cur nt owner (' different than applicant): Name: Address: 3) Property Description: Lot Size: Subdivision: Address and/or directions to Properiy: Phone (home): 9 l4 - 36 �- � �G � (worlJcell): Phone: Lot #: � yes 0 no Does the site contain any jurisdictional wetlands? ❑ yes � no Does the site contain any existing wastewater systems? ❑ yes ❑ no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency7 ❑ yes O no Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: . OResideatial ❑ New Single Family Residence Maximum number of bedrooms: ❑ Expansion of Existing System If expansion: Current number of bedrooms: 0 Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no �Noa-Residential 1 ,��/ T e of business: ' V YP Total Squaze footage of Building: Maximum number of employees: Maximum number of seats: � G X y� S7 Water Supply: ❑ New weli ❑ Existing Well ❑ Community Well � Pubiic Water � Spring Are there any existing we(is, springs, or existing waterlines on this property? O yes � no 6) If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional 0 Accepted ❑ Innovative ❑ Alternative ❑ Other p pnY I cert� that the infoYmation provided above is complete and correct. I also undersland that if the information provided is inaccurate, or if the site is sub�tly altered, or the intended use changes, all permits and approvals shall be invalid. Sign��u(�e{9w�/ Legal Represet '� Supporting documentation required. � � � Date • Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. • A completed `LotPreparation' form must accompany aay application requiring a site evaluation. / � n I � � \ T r . .-. . ' " . ' _ ' _ .. ' _ _ _' ' � 1) ' �� ' � T , 1 \ � � � �� \ � I � � � Buiiding Additions/ Mobile Home Reptacements Tax Map #: A 23 Parcel#: I$b Address: (c(. a� ..reeX ��. (P�� Lec�{�on� .Sern„r� n!c_ �7�y3__ L Approval Requested for: Mobile Home Replacement � Building Addition . Applioant Name: �}�n «� 1�1 � �c (a S Sfa m�� Ki � Address: �Ma��q ) ij1_ P�,fe Qd . J �------- -- � . �� Phone #'s: �1 l �L- Permit Located: _�Yes Installation Date: 5- l y- n� No Design flow: 3 GO (gpd) Current Contract wi±h Certified Operator on file (if required): VfTater Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: I� -1 - S (date) (Applicant's signature if site visit is not require ` c f�F%Y°vr�� .GK f�d��i'toY� �1� X � � r^ tr/ Addition/Repiacement Approv�d ., Env' onmental Health Specialist �- �7- �S Date � Person Couniy Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573