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]:�s�.�a-���.-�„ ��.��.:1 IE���.Il�7�
Applicant: ��'^ �4i^S�
Address/Location:
!�. .. -- ' -� _,�. � rD% �i
i �,
�.✓o�
Taz Map: 0�'3 Parcel: �U �
Subdivisicn C��r.✓4 �
Phase/Section/Lot #
IL���[Qi .•T.
v Improvement Permit
Permit Valid for: Five Years I� Non-expiring /
Type of Facility: �� 3�3te. New � Addition _ Waier Supp;y: �V'e �(
Number of: Bedrooms _� / O cupants !O / Employees / Seats: Projected Daily Flow: Go o gallons/day
Propased Wastewater System: p r3P 5 W�l1 u�, D Type: �7r6, e
Proposed Repair: _�, �,-; � q�f,'w, Type: �0.
Permit Conditions: �P,2 5� �'� 1��Q �-,
Authorized State Ageni: _ w� L:, Q�'�.� Date: 'S �5'�
(X) Owner or Legal Repres$ntative: ��� � � Date: 1�,-�',—i�
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is th;, responsibility of
the applicant/property owner to insure that all Person Coanty Planning and Zoning and Building Inspections requirements are met. This
improvement Permit is subject tu revocation if the site plan, plat or the intended use changes. The Improvement is not affected
by a change in owaership of the property. T6is permit was issued in compliance with the provisions of the North Carolina `L�ws
ani[ Rules 1'or Sewa�e Treatment and Ilisnosal Svstems'(15A I�TCAC 18A .1900). Neitner Persoo County aor the Environmental
Health S�cecialist warrantS thal the septic system wiil continu., to function satisfacto::iy in thc fature, or that the water s�pply widl
remain potable.
AutLorization to Consiruct Wastewater Sys#em
See site plan and ada'itional attachments (�.
x
Proposed Wastewater System: �P►gPs �/I J�uw�,fl (*}Type�6, 2Design F(ow ��a gal./day
New � Repair _ E:cpansion _ r Soil LT�: � 3a gal./day/ftZ
Type of Facility: �✓312 c�Gt�asx .E- 3 V3�2 / �Pes. $a.sement: �Yes _No
(��) System Types It'Ih, Iljbg, IT�, �tnd V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank � o gal.
Drainfield: 'Total Area � Q� sq. ft.
Trench �Nidth � ft.
Pump Tank So c7 gal.
Total Lengtl� 3 3� ft.
Min.Soil Cover �° in.
Grease Trap � gal.
Max. Trench Depth 3 Z in.
Min.T'rench Separatian __�__ ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold _�_
Specifications:
�c�+-�e �� S r P'
SI c�, .S 4-e�e
�c� S .
Authorized State Agent: (�v►� � �"�''e,� _ Issue Date: ��-�"! 7
Permit Expiration Date: 5`� S-- Z Z
The system permitted is: Conventional /Accepted / Alternati�e �/ Innovative . I accept the conditions
and specifications of this permit.
{k) Owner or Legal Representative: Date: �'�!— /'�
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
F�JC�eVeive
PY�m�a
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T a x M a p: 3 P a r c e l #: o t D S D a t e: S a s' ►
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Lene B'ap Tap (Sch) Tap �lopo L'me I.engtl� &'�o�v !�oot
# Diaffieter(imm) ( �) �;. ft)
1 2 � �(D ?. � ho � . la
2 7 �'• S•S 5�1 • 11
3 � Z �o S•S a � � �1
4 'lZ �.1 � � . o
5 '�Z �l a 7� ! 7v � ► l'�
6
7
$ � oZ V�PH �4— o �-Q-
9 �
.80 �
�3a ft of line x 65 gal. per 100 ft=�' �; 100 =—' gal
?5% x•—' gal =� ga� ger dase 3s gal per minut� (b"Pm) _�'!ow Rat�
Friction �ead N r r
I,oss: �•3 ft per 100 ft o supply line x�� ft of supply.line =100 = P ft
�ft x 1.2 =� ft of friction head �.
Manifold Size: 3`� "�'orce Main Size: 2 " PVC
�Qtal Dya�a*ic �easi -^' �� ft of Elsvatz�n h�ad +'Z ft of P;essur� }:��3 +� ft of
Fricdon Head = Z�—TDH
Pump Reqnirement: 3� GPi1�1 @ a�• ft of Head
Daa�vdown: �$� ga� per dose ���1 per inch =�" i,1ch drawdown per dose
zS
Ce�ea�ll De�a �for�s�ton
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SeLe�dedOPVCTm 11tm�p�dap .
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Si�e ;Ylra¢rial Flo:v GPYI
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;, " 5c1:ed 80 ►2!
=, " Sciied s0 1:.�
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Sloped To Sl�ed Water
6" cove: ,•
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i.
Izdet Fmm Septic Tatt]c
+1" SCii 40 PVC Pipe
NEIvIA 4X Simplex Contaol Panel
4" X 4" Pressare Treated
12" Sep�xation
Electrical Conduit �
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�• � ` Access Cover• � •- ' ' e ~ ' •j � � � II
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f�� Po:tlmd Ce�m�.mt C,xvat •� Axtiti Sipkon Hole' ♦
$�1
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Cl,eck
Valve '
High Water Alatm L�vel
: �' ' (6" Separation�
:: �. HiSltLevel- pump pxt -�.,��
� , ;: / il fiVaparLock
� �� Drawdawn Ho1e
• .� � iQP �1)
•Low Level -Pamp Ofi ------'
,-.. . •
.' ' Preca�t Concrete Taalc
..•; (MateaalStm.�tk>3500
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T�x M��� � F�i�cel # � '
Stihcllivisioi,i '� �
�Ph����s�e 5ect�ioi� Lot # ;
Duct SealHotk
Ends Of The Con�uit
-" 24" Mini:so�m
.. ., • ,
Theeaded Gate Valve
Uaion / "�' n
Concrete Risex
6" Separa{icx
. • ' ; i �
��-POYtidNd C017C2pt8 CKOtlt -
. s 14125t1C • • - '
� �� supply. .'�,. .�Pe�F�edWith
� �: , PortlandCeme:tt Grout
• 4utlet To Distnbuti�on
if.Nplon 2" SCH40PVC Pipe
4" Conciete
'SI� Block
':. _;�'. •. . .'.
,e F1oat Wues .� �
.. -
•r
i
FJaats ,�;
f..Rsmovable • � �
F7oatTree '�
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....�'sL _: i:
�� 5� a GAZ.La1�T PULV�.' TAN.t�
" PUMP ttA7ING � .
Pvmp Mu Rated ?o Deliver
� ?v� Gallons Per Minute ,
Against Z Feet Of Tota.l
Dynami.c Head TON).
���,Sf �����l�Y
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]E��smffi�����.Il lE��mIl�l�
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Name: r5��
Subdivison: C�
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Site Plan
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9)
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w���t (�'Qivt�e'S�l RYQ�.
S�OW'✓l G►rtA.t� ���'1�e�
C��n C1 ay .
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� lo ` o�' �ok�'o�r
�t�2 � (� � o�cl- h��Prh2��{'� a�
�o `�,M vc���,.a l C a ke L�v�e (.
� � � �,,��c� �.i..Q�e�.e�
�✓1or2 S�t+�c�Q v1�2���
C
� " ���i ,�'
�,�QS
a
iress:
Lot:�
�� �
Tax Map: �
Parcel: ��
EHS�,�U►'h �c
Date: ��a5^ t
�
;� . .f � � '
S i
-3�P �/�, \
v
U' � �• , �% /
�1 � � '� 9� �o���' S
� �w+' � 65,.
, A N
3 � �
G
` o� g9! �
�_ 63.74___.p� 3�L g0 S
S 03' 12 33 W �
o �,
� N
System Type:� — �,
Septic Tank: 0 o gallons
Pump Tank: �5�D0 gallons
t
Total Linear Feet: 330
Max.Trench Depth: 3Z ��
� p O
c
�
v
om�
--1 9 �
.+'T1 ►"�
r� _ t
scale: % 50
Note: 1) Drain lines represent approximate contours. Drain line locations must be flagged prior to installation.
2) Contact Person County Environmental Health with any questions (336) 597-1790.
Additional Comments: �
�
���, sf ���.� ��
�^ � � ����
I-�" �n.�aa-�xn.a�a�n���.Il IE�a��.Il�II�n
Applicant: �''1
Location: ,
Operation Permit
System Type (From Table Va): b�
Type V& VI Expiration Date:
Tax Map � �'3 Parcel # � �
Subdivision � ��An�,Ja �r
Phase/Section/Lot #
# of Bedrooms .S
Product (IIIg): t' t�� P �
Type V& VI Renewal Date: ��
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.
��
�
(Authorized Agent)
/�t �-�'' �
(Licensed Contractor)
�X
/ �r
�� �-�
�r��
�
��
/���
./
��
.`��°�
. �e�
p,,Q,�
s�alE �_
PCFiD, rev. 12/14/12.
(Date)
��� «
(Date)
Line Length
z so �� �'
� �30 �
70
Tntal
Tax Map: Parcel #:
Septic Tank System Checklist (Type II-I� System Type: �� ����'l f
Se tic Tank nitiaUDate
State ID & Date: - 1- � --(
S
Capacity: t , �p f
Tee and fil er �/'
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box levels set)
Serial
Pressure Manifold
LPP
Notes•
Pump System Checklist
Pum Tank nitiaUDate
State ID & Date: �p-- �?-t 3� -<�
� a s� ✓'
Capacity: ��?�
Riser (6" min.)
NEMA 4X Box
ModeL•
Piggy back plug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Mani%Id
Number of taps: 3 �-Q�t�
Size and sch: �
Contracted Certified Operator (Type IV Systems):
Notes:
Tank Com onents InitiaUDate
Pump modeL•
Block (4")
Nylon retrieval ro e
Float tree and attachments
On/Off float swing: in.
Alarm float (6" se aration)
Anti-si hon hole
Check valve
Threaded union
Gate valve
Conduit sealed �
Outlet sealed
A proved and secured riser
Su 1 Line
Size and material: Z in. '-�c�ch. r,�
Length: ft.
���.sf ���.���
�- � � ����
]E�ca�nsoaan�n.mssad�.Il IE3L� �.Il �]�a
WE� PERNIIT
(New Repair_ )
Tax Map: �3 Parcel: o��
Subdivision: C���w�
Applicant's Name: �2.�t .%a�5�'�ry
Mailing Address:
Phone Numbers:
Location of Property: (1.r v�
��
Lot: �
� -� �1��,��. �e� ��, .
o i� � — �2� SQc
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County 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/Comments:
Permit issued by:
'�Tew Well: �
EHS ate
Location: ��
Grouting: __��
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Date: S �i'-�'(
Certificate of Completion
OLiner:
EHS/Date
�_ � l � Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
�jQ Y ✓t � �� License #:
License #:
Date:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S, Morgan St.,Suite C
Roxboro, NC 27573
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
WELL CONSTRUCTION RECORD (GW-1)
�1. Wel Contractor Informa6on:
c� n n�� i e�, ��,c�� i-�
Well Contrador Name
_ ���(,`��
NC Well Contractor Certi6cation Number
Barnette Well Drilling, Inc.
Company Name
2. Well Construction Permit #: A� 3
Llst al! applicable well construcfion permits �.e. UIC. County, State, Varimrce, etc.J
3. Well Use (check well use):
Wflt¢r SUppIY Well:
QMunicipal/Public
(HeatingfCooling Supply) �x Residential Water Supply (single)
ommercial �Residential Water Supply (share�
Non-Water Supply
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Techno(ogy
Geothermal (Closed Loop)
Geothermal (Heatine/Coolin�
QGroundwater Remediation
�Salinity Barrier
�StoRnwater Brainage
�Subsidence Control
�Tracer
i�Other (exn(ain under #21 F
4. Date Well(s) Completed: �- '�g —r� Well ID# �.Z- �
Sa. Wetl Location:
�� � a � -� , -
Facility/Owner Name � Facility ID# (if applicable)
C f eA2.y,�Af� 2 ��1J �.u��
Physical Address, City, and Zip
T ��.5 o N ZD3'
County Parcet Identification No. (PII�
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laUlong is suf�icient)
� d:�" / 4�iJ N`79 - a 6� 7�. W
6. Is(are) t6e well(s) Permanent or �Temporary
7. Is this a repair to an ezis6ng well: �Yes or �i�
fjthrs is a repair, frll oul lviown we!! consrruction injormation and ezplain the nature ofthe
repair under »2/ remarks sec[ion or on the back ojdris form.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, on(y 1 GW-1 is needed. [ndicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: i 6 � (ft)
For multipfe we[fs list nl! deplhs ijdifferent (examp/e- 3Q200' anAZQ100')
10. Static water levet below top of casing: 25 (ft.)
!f water /evel is above casing, use "+"
11. Borehole diameter. h (in.)
12. Well construction method: Air rotary
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES t
FROM TO DESCRIP'fION
�Q� «' ��it J� ��'l
� � f4 � 7�+� ' I
15. OITI'ER CASING for maltitased welLa OR LiNER if a linbte
FROM TO DIAhiETER THICHIYFSS MATERIAL
� fA QD �t 6 1/8 ��. rl� 2.t U G
16.1NNER CASING OR TUBING eothermal closed-loo
�xont To DfAMETER r[nc[avEss hu'rewwL
ft. ft ia
(t ft ia
17. SCREEN
FROM TO DL4METER SLOT SIZE THICKNESS FiATERGL
� tt rt. ia
fG ft I ia.
18. GROUI'
FROM TO MA7'ERIAL EMPLACEMENT NIET[iOD & AMOUNT
� 2,d n- GraveUcement poured
R, ft
ft fG
19. SANDlGRAVEL PACK ifa liable
FROM TO MATERIAL EMPLACEMENT6fE'[HOD
ft. ft '
ft. tt
20. DRILLING LOG attach additional s6cets if necessa
FROM TO DESCRIPTION cobr, 6ardnw, wiUrock io sae, etc
L�. '�,C " (/� e t b"..ttal..o s
�- $�"" ' �Ka wN So i l
tS' �- 6S f� 'S,Q o►�c.11' e
�S�- /66 �- G R� (�,� c f�
ft. f�
ft ft. '
� �
21. REMARKS
22. Certification:
/��?;►�ccti.. � � �.�,�' 2- "�' 1�
Signahue of CertiSed Well Contractor � Date
By srgning this jornr, I hereby certify that the we!!(s) war (wereJ conslruc(ed in accordance
wuh /SA NCAC 02C.0/00 or /SA NCAC 01C.0200 We!! Constructron S�andards and that a
copy ojrhis �eeord has been provided �o the we!! owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary_
SUBNIITTAL IN51'RUCTIONS
Z4a. For All Wells: Submit this form within 30 days of completion of well
conswction to the following: ;
Division of Water Resources, Information Proccssing Unit,
1617 Mail Service Center, Raleig6, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy �of this form within 30 days of comptetion of well
construction to the following:
Divisioa of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Ceoter, Raleig6, NC 27699-1636
13a Yidd (gpm) �- � Method oCtest BIOW@(i ZO Mln. 24c. For Water Suoolv & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfecfion type• CIIIOfItI@ Amounh 1/4 CUp completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Cazolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016