A23 204�����i�
Application Date: � t3 � 6p `�•.�� � r������ Tag Map: ��-3
A m o unt Paid: 0 � 4 �4Q , �:;."� Parcel#: �D-�
Receipt #: i� q ( �� �' � ����
� ���s ��.¢�Il ��ffiIl�Ila
�� � g 3� Application for Services
Services Requested
Q'Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
0 Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
0 Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
0 Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: ��� ���
Name: S��i C�`Ecv�t�.ic � L_ LG, —
Address: ' S F_
CN � �'ns K� ' � � �-
2) Name and address of current owner (if different than applicant):
Name:
Address:
Phone (home):
(work/cell): _
Phone:
33� - s ��f - d £sg o
3) Property Description: Lot Size:�� � Subdivision: �E��� Lot #: �
Address and/or directions to Property: C�,+J i'.�,��.Av.. '�.d � t d'�+a1
❑ yes �d no Does the site contain any jurisdictional wetlands?
� yes Q no Does the site contain any existing wastewater systems?
❑ yes C�no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes C'Yno Is the site subject to approval by any other public agency?
❑ yes �'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:
G�esidential ' �
ew Single Family Residence Maximum number of bedrooms: J / Occupants:
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no
❑Non-Residential
Type of business:
Maximum number of employees:
Total Square footage of Building:
Maximum number of seats:
5) Water Supply: L'� New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? � yes C�no
Please note any known ground .water restrictions or sources of contamination:
6) If applying for `Authorization to Construct', please indicate preferred system type(s): _
0 Conventional ❑ Accepted ❑ Innovative O Alternative ❑ Other Cd�Any
I certify that the information provided above is complete and correct. I also understand that if the information provided is
inaccurate, the site is subsequently ered, or the t ende use ng , all permits and approvals shall be invalid.
� ��.,s� j I z /w
Signature (Owner/ Legal epresentative*) � Dat
* Supporting documentation required.
Permits are valid for either 60 months or are non-ezpiring when accompanied by an approved plat.
A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant: I�b �ASQ
Permit Valid for: Five Years
Type of Facility: .
Number of: Bedrooms � / Occ
Proposed Wastewater System:
Proposed Repair:
TanFrQve*ner.t P�rm:t
Non-expiring �
New � Addition
�Emnlove,es / Seats:
Tag Map: �3 Parcel: O��
Subdiyision r�4
Phase/Section/Lot #
VVater Supply: � i
Projected Daily Flow: 3 O gallons/day
Type: �
Type: �
/,� �
Permit Conditions: S.PP �1�T-'� S�'��
Authorized State Agent: � ���"� Date:
(X) Owner or Legal Rep sentative: �� ,(, ,,,_ . Date:
The issuan�e of this permit by the Healt�h deparCment does not guazantee the issuance of other required permits. It is the responsibility of
the applic�ndproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
fmprovement Permit is subject to revocatioa if the site plan, plat or the intended use changes. The lmprovement is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisioas of the North Carolina °Luws
a�rd Rules %r Se►vag� Treatment and Dunosal Svstems'(15A NCAC l8A .19U(1). Neither Person County nor the Environmental
Health Specialist warrants that :he septic systcm will c�ntinue to fanciion satisfactorily in the future, or ihat t�e water supply wiil
remair poiabfe.
Authorization to Construct Wast�water System
See site plan and uc�ditiortul atiucizmenis ��).
�.
Proposed Wastewater System:�lrr� f� ' p� —�5�. (*)Typ�� Design Flow �3�OD _ gal./day
New � Repair _ Expansion _ Soil LTf�R. ,�? S gal./day/ftz
TypeofFacilir,�: '�}�j� {Qps, Bssement:�Yes _1`'0
(*) Sys�em Types III6, Illbg, IY, and V, require periodic system inspections by the Ferson County Health Department.
/�lIR QIS����A�1� ■���
Wastewater System Req�ireraen±s
Tank Size: Szptic Tar�k �� gal. Pump Tank ��O a gal. Grease Trap '� gal.
Urainfield: Total Area QQ�O sq. ft. Total Length 33 Oft. Max. Trench Depth �� in.
Trench Width � ft. iVIin.Soil Cover � in. Min:Trench Separation � ft.
�istribution: Distribution Box / Serial L�ist►.•itution_,_ / Pre.ssure Manifeld �
Specifications:
,�►�rthorizzd Stare Agent:
'f-
�✓`2�
issue �ate: i � y�'J
Permit Expira±ien Date: �-f r- 22
T'he system permitted is: Conventional /A ted lternative / Innovative . I accept the cond'tions
a��d specifications of this per!nit.
(Xj Ownerr or Legal i2eprese�tative: Tate: '2- ��
Person Counry Environmental Health, 325 S Morgan ,St, Suite C, Roxboro, NC 2757.�%ph: 336-597-1790 (rev 5/12)
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:I���w-�.� � �,,-,.-„ ��.�.�.IL ILHt � �II�tI�.
Sloped To Shed Water
6" Covex•
..�
Inlet Fmm Septic Tank
4" SCH 40 PVC Pipe
1dEMA 4X Simplax Control Panel
4" X 4" Pressure Treated Post
12" Sepdration
Electrical Conduit P
T�x M�� % � P�rcel # � �
� IIhC��VIS1011 �/ • � v
Pi�.� : Saction'Lot #t
� Du.ct Seal Hoth
i Ends Of The Cozuh�it
24" Minirraun
.,
Threaded Gate Valve •
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• ` Acceis Cover• • , ' . ; 1 ?
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o ' ' �� : � ; .'��. �'" . ;
�.: Opening Filled With � Zip Cord
Anti Siphon Hole Ties }
Portland Cement Gmut (Down Hill) _ �
Check
, Valv�e
High Water Alarm Level
' (6" Separation�
,. High Level- Runp On -�—.�,�
.. �':
/ 1 rVaporLock
Hol� _
. . � � 7 5 Dravfdmvn �Up Hill)
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. Low Level -Pump Off --^r'
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' Precast Concrete Tank
� ;.; (rriatesial Stren�th>3500 PSI)
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` �•�:• • • . ' � - ' . . . f
4" Concrete
Blr�ck
' . . '�
Concrete Riser
S" Sepaxation
• '• ' . %r ..tJ.;l• .
',r:.�.-Portl,anci Concrete Cnout
Mutu • - '
� Opening Filled With
°pply PortlandCementGrout
,� . •
Outlet To Distxibution
2" SCH40PVC Pipe
e F1oat Wires . � �
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i
Floatt .
�Removable • •
F1oat Tree , ;
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� GAT,LON P�U�IIP T�TI�
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?E�-�� ���t ���l�E�. Owner.
Tax 1blap: �3 Parcel #: 0 Date: 1� l�'7 _
7—
I,�ne Tap '�'ap (Sc�) Tap �'lo� �ine ���g� �oe�v I f�ot
# Di�ynetea�(�t) { �a) -; {ft}
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2 �� l�o � , � s
3 cl� � . D
4
5
6
7 ��c
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9
10 .
3 3a ft of Iine x 65 gai. pez 100 ft=2� S� —'9 ; 100 =?! 5 gal
75% x� ga1= -f�� gai per ciose Z�_ gal per minute (gpm) _�ow i��
�'rictaon �ead �
I,oss: /' %�ft per 100 ft of supply line x~�O0 ft of supply. line =100 = � ft
�_ ft x 1.2 =_� ft of friction head �.
li�anifolci Si�e: 3- Y „�orcx 1VIain �ize: �- „ PVC
�otal Dyg�mic �ead -- �ft of Elevation head + Z ft of Pressure head +.� ft of
Fricrion Head = 3S TDH
Pump Itec�a�a�ntes�t: ,��, GPM @ � S ft of Head
Dra�vc�own: l�/ �al per dose � 21 gal per inch =? S inch dra.wdown per dose
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Taps 4ff one sifl�
:or Lautriae �oth
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Sie lYlcueriai Flmt� G��I
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SITE PLAN
Name � Tax Map# �� Parcel# v!�
_ _ Subdi isi �' Section/Lo —r
���
^ � � � ( l = � � � uthorize Sta gent Date
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`� �� System components represenf approxi»�ale contours only. The confractor must Jlag rhe system priar to beginning the
�`� � �� } inslal/alion to lnsure tha� proper grade Is maintatned.
� � Note: An Accepted system may be used in place oja convenlional system withbu! permit authorization or modification.
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_ _ . - — -- --- ---- . _ ---_ �_— __
-- - - -- _ _ .
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- \�� ``� REFERENCE I S MAOE TO THE
� RESTRICTIVE COVENANTS RECORDED
_, _� fs�� � c' \�� ._ AT OEED BOOK 698 PAGE 301.
i �J�n7� �� ` �_` '`��` WELLS MUST BE 50' M I N I MUM SETBACK
'�` FROM ANY DRAINFIELD AREA OR SEPTIC
�� PUMPLINE EASEMENT.
�
`. �
\�`=7,,�0 � � � � WELLS MUST BE 10' MINIMUM SETBACK
\� � C L E A R W A T E R� � FROM PROPERTY LINES AND 25'
\ MINIMUM SETBACK FROM THE
� \` a L A N E , ' BUiLDING FOUNDATION.
' �� 5 O� R/W CONSTRUCTION IN THE PROPO5ED
� B U I L D I N G A R E A S M U S T M E E T A L L
' �J �� (PRIVATE) i /f PERSON COUNTY SETBACK REQUIREMENTS.
� \ , /
. __ _
�
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� � , _ ..._.� / UNE BEARIN� DISTANCE
W � ` L1 S 05'15'22" W 35.65
ot� ��`-- �—!\;; ;. - L2 S 50'37'02" W 55.42
L3 S 32'55'42" E 46.89
o a � �\ �`� , L4 S 04 54'50" E 35.13
i� r� PROPOSED
� YYELL AREA � �` \� � WASTEWATER � S �1'09'19" E 39.66
Z (SEE NOTE) ��� �� f PUMP LINE L6 S 89'34'30" E 49.58
� �. �� EASEMENT L7 S 35'02 25" W 52.17 •
� � . � � �� � . � L8 . S 7G'28'S5w W 56.56
v � /��� \ • L9 S 8417'30 W 55.97
s / �� � L10 S-;4554'54" W 37.12 -
.�1" � e�l � u`s \.` �� 1.11 S�'3521:49" W 22:51
N 61'S6 y� � <g �� iS�,� \�� � L1;2 S>73'22.'25" W 32.75.
� 6Z� . • o����,� .; ��\ L13 S 81'08'18" W'. 37.32
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� � PROPOSED A C I � E S ,''`��,_ ,` / ' � �
BUILDING ♦ � i ��
� AREA LOT 7 '� �` � � � ,
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� 420' f q, . "CLEARWATER" ; '7`' �/ ''�-� ,, `
h : � r
� � CONTOURJ ^�• ,�� P. C. 15. P. 632 � ;� � � _,_ `
/ �"� � � / .
� N s�� �� � / � �
--------- s�;g2ss» � /o� ., , f +
�
2 �� DRAINFIELD ' ; /
� �o, ' AREA FOR l; i DRA I NF I ELD
� � j � LOT 14 ,�/� AREA FOR
� S � s �9 �� � �554� /� ; LOT 9
Ss�2' �y � MQti►�O(c� l ; ;
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Q�l y��/�.� ' ��. �, , L6 ' � -C'�� LO"
� O � �y°� ,���` � .� � , � /� � / "CLEAF
►3 C � 2 ��' i ; � � � ,' P. C. 15,
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V � � APPROXIMATE � LS � /
; CEMETERY � �0� � /� � � i
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f?� 2j � C� C�C� � �;��� i ; ' ,�, � ; � , ��WASTEWATER �
os� � ; ' '� � � ' PUMP L I NE
�yQr ✓1 �Il'� � � i � v � � ' EASEMENT ��'���i I
� �12 � ; ,
l.� 3 � � ' � �
i r
�r �� � / DRAINFIELD i � ���'' ' �
�'g 1 Y�vIC� ��P� � 420. / AREA FOR L;�����+`r `` r' ��.� /
LOT 11 � ' ` �
CONTOUR 1 ; �`. �
./
C � DAREAFFORD �,
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�,M1�1��� z� st`„� 1 S�r�( �� i� LOT 10 //
1 ► � � �/
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(/�t S�u�b�'�G-� �.�/�t�'� C��QAr�v� �♦ ��� i �' ��i
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�4��t�e�� Ct�-�4t• L_-�_------�� 420'
� CONTOUR
� ��v vt� � C�r s"�-�r b G2n�t-2-�-�-y , ___-------- _ _
C
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��ra�n�c-�aa�a�na.�mIl ��ce�.���n.
Tax Map: � P rcel: d
Subdivision:. C�•29(►-r,✓o�,
Applicant's Name: ✓�� � � �
Mailing Address:
Phone Numbers:
Location of Property:
WE� PERMIT
(New Repair_ )
Lot: �
,�u' `%,rulQ. ✓i .
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and Counry regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Coraments:
Permit issued by:
�
Certificate of Completion
Tew Well: �
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
EHS/Date
���-�-- Ckr-�i-�j �
-� -��.�
�
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✓'
Well Driller: �''�'�-��
Pump Installer: `
Approved by: ,�. '""Q�
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmentai Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date:
l�'s'�
QLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: — l
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
li/26/13
Nov 1717 01:15p Barnette Well Drillinglnc
WELL CONS'£RUCTiON RECURD (GW-1)
i. Wel) Cootractor In�orroatiou:
�t9 �Rl !�L' � • �� 1 / 7T
WeSI Contrastor t�[ame
�37G-�
NC Well Contracter Certifintiort Number
Barnette Weil Drilling, Inc.
Company Name
Z. Weli Construcdaa Permit#: � � �
list o1! appfuable well coxstneation orrmua (ie. UIC. Cnwuj+, State t�arirorte, etc.J
3. Well Gse (c6eck well use):
Water Supply Welt:
] Agricu]tural Q MunicipallPubEic
�GeothertnaL (EieatinplCooling Supply) x�Residential Wa[erSupp!}• (single)
�lndustrial/Commercial �Residential WaterSupply(shared)
w�t:
Aquifer Recharde
Aquifer Storagc and Rec�very
Aquifer Test
Experimental Technolaoy
Geothermal (Closed Loop)
Geothermal (HeatinP_ICooling
�Csroundwater Remediazion
QSalinily Barrier
�5torrnwaur i)rainage
�Subsidence Corrtroi
�Traar
�Other (cxplain under f�21 1
4.Daie\Vell(slCompleYtd: %116 j % ___ w�uina %��3
s�. we�t �u�a:
�D� �!'Se L-O� 7
Facititt•!Ow¢c Nune Facility II�ti (if appiicabla)
e � �e �I d� r,v.� ,�'
Pliysical Addrass, Ciry, and Zip
�i�l� Sd,� _
Count�' Parcei Identifrcation Iso_ (PCI�
5b. Latitude and [ongiNde in degrees/minaceslsernods or dcams�l degrees:
(if wdl fic1d, oae laviong u sufficient)
36 .�f 4� �� N 7 4. oG �'6 �- �•
6. is(are) the well(s}�r�rmanent or �Temporary
7. Is this a repair to an eadsting weU: QYes or ��
ljefris i.c a repair, f.11 onf fmmam well croxurvaion urformciron a»d up�airr rhe na�ure of ihe
repair under �21 remarkt suion or on fhe 6acfr qf 1hLs jorm.
8. For GeoQrobelDP'!' or Closcd-i.00p Geothermal We14s having the same
r_onsvuctioo, onty 1 GW-t is rueded_ IndicateT�TALi�FUMSERofwells
driled:
336-598-9275 p.1
Use Only:
/�foK.- �� « 3 �l
2Zs"' z3° � ZZ�'q'�
15. OUTER.CASIING for ma3e-ctsed xdb OR L NER if. ■
RrtotK ro nu.a�eR renC[aress
� rc. 7 r� �- s 1 t8 ;�. ;�',� z l
iG[PlIYERCASINGORTUHOVC. thennslda ui-lao
�ot�t rn otnn�reR rffi xx�ss
�y it ��
ft. t6 1O- i
17. SCRF�I�I
�ohx TO DLlM1i6TER sLorsrca ��
Q ft. ft. is.
CL ft. 1°- �
� �d f� Grdvellcernent
� ti
Ec. F�
ID/GRAVEI:PACK �fa lica6[e
Tp MA'lEAfAL
ft. R.
R. k.
� ft.
6.� K.
Z4� �L
fL
sc
r�.
n
22. CertificaYian_
v ,
Sipnazure of Cati6cd WeU Cantra�or
sy:;��b iha fom,. 1 hereby etr1� rho� +l�e wefl(s)
wi�h J3A NGiC GZC .OilNJ oi 1 SA NCAC 0]C .Oi00
rnpv ofM�ls record has 6een prr.vidcd 10 the wrll nwne
Z3. Site diagram or additioaal weti details:
You may use ihc baak of this page to prorde
coastruction details. You may also attach addit
SCJBM[TTAL iNSfRUCCIOIYS
9. Total wtll depth below (aud surface: ��v ��-) 2�1a. o At1 Welis: Submit this fotm withiril
Fa ruultipJe wel�a lur af! deptles• tJdefferent (uvmp/e- 3(al?DO' und 2�100� COnStnlCtlon t0 the f011owiilg:
10. Staric water Fevd below top of casing: 25 (f�-) Divisxoo ofR'ater Rcsaurces, lnform
1j�o:er:ever is ahnve cnvrb, ure "+" 1617 MaiE ServiceCenter, Ralei�
Ll. Borehole diameter: C3 (in.) 24b. �or lnfection Wells: ln addition io sendi
Air rotary abovc, also submit one copy of this fwm tvith
12. R'ell eonstructiaQ metIIod: conswction to the fo]lowing.
(i.e. auger, rotacy, cabtq di:ect push, ac.)
Division of Wzber Resources, Undetgroun�
FOR WATER SUPPi.Y WELLS ONLY' 1636 Mail Scrvice Center, Ralei,
i3s. Yieid (gpm) �� Method oCtcsC BIOW@d ZO MI[l. 2q¢. For Water Saoolv & 1'ection WeFls: J
tl�e addcess(es) al:ove, aiso subaiit one wpy
13b. Disiu[ection type: CF1IOni72 Amount- ��4 Clip comple2ion of weli construction to the eounty
where constructed.
�1�f6 17
D�c
(were) caer�ructed i: acccurl�mce
Consrructian S�oJ+rlards rnrd thar a
ianal well site detsils or well
Pages if neccssary.
30 days of comple[ion of we}i
on Processing Unit,
NC Z7699-1617
� tbe form io thc address ia 24a
30 days of compiction of well
lnjection Control Froeram,
h,iYC Z')699-1636
addition ro send'mg thc Corm to
�f this fonn within 30 days of
aeatth departmsnt oP the county
Fomr. G�V-t Mocth Cazolma Department of Environmental Quality - Division of Waler Resattcces � Revised 2-22-1016
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Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes:
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