A23 81�e�-cto -f'he. `` per � `' '�5� � See � �'
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. ` na �o o� • �Ltl�e �a� adD�
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t,�e �er�. -�old
6 no c.ltia�. e�
l � �'�+ � 5 � S �'�-
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�ii�e c.a.se .
Our Se�tiC- 'fiel�' i5 o�a� �
' �ax Mao �k '
Peraoe Courtht Heaith Deaartment
Environmerdai Heaitll9ecllon
-_�. • -• ' �_:� �
�' �1anc � Caeor e Ste-I-te r►
1) Psrmit raqu� e : tlpc�ospacliw an�me�:.
Hans Pho� Z. - 5 a. � Ad� r' G. �
6tnheas 2 - i % (o �
Zj N�ne and add�+ess � cunat�t owner.; A.t�¢. 2.Qrrltre_ �� n hsyl v4 n i a. l5 2�$� .
�' 2� e5 Sernora. COak po�nte,
3� Psop.rly Daurlptlaa: at�x Ta�
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t one rn , le�
•� Ptopoa�d Uae and 94v�ttsce Descriptia� answet eacl� af ihe to�wing qu�ns: � �''
a) P�OQosed �. � � .
b) SQdc 8uit Q�c L. S�gie 1Nide 0. �arhle Wid�e � �
d Ntunber oi 8e�oomx � Number af o�• ar paople to be seivac�
e) . Ha� Yea Q No � it` yea. # af b� tbdure�
•� Gacbage Dtsposak Yea 0. No []
� qhriernioc�sai P�ad S� VVidlh: Dapltt
�? ��Pph►'1� R�te o p,ew a oc e�a �I. P�c 4�r a. sp�e a• W
Ara any w�ils on a�oin�ng prct�ciy't Yes [I No a lt yes, toca�on
� Pl�as. inau�. c.eiiad sns�m 'iy�: t�a can � r�la� N cr�r ot ya�r p�)
e ha✓e
dw� a
�. `�,�'
We ��
conve�mo�i Yo�ed c.aMatlonai _, A� �Jnnova�+ra S� L3e. b�c � 1 t o n
. � �. -�'he. �o1r�t' � �ea r u� r, 1 �
boa-th�we , �rve.
►'Ylcx,-� o � p�oper-t mctrl� rS � ,,�,�,,, p .�. � -t-o -t�h c
� �
c�.re t� 11 ' n�� pla c� . . � � Se p-f ► �-P; e �c�
pie,� Sec a�1"��c.hed c�.Y sr� aLL cow��s aro ut�s oF � t�op�t.
rrnQ� . sr�� coa�s oF au.�oposEn sn�ucTua�s.
PI.EA�SE ATTACH SURVEY PtAT OR SRE PU1N TO THIS AP�CATtON �
I he�eby rtiake apQBcation to the Pe�on Can�ty Health Depe�trn� ior a a�e svabuatlon ibr 1hs on-aits seawaqo ��t+�n �
tlte above�descri�ed propedy. t apnee H'�at ttte �b of this appic�fon ace trt�a and c'ep�t tt� awodtntun i�iea bo t
ptacad � ihe pc�e�ty. !�u�der�and �the s�e ls alberod ar�s b�ded uas �. tha pertn� aha�l bomit�s fiw�d. l�
that aa ap�rt. 1 a�n ies�ns�teE far td�g gad �9 P�'oP�Y �. � and makicq tt�e a�e a�is �Oc ti
p�onna! af tt� Per�on Cau�ty Hea�h Dnpartcnent to cactdtu� thair waNmtlona. l ta�nd th� t am �%r tta�ing �
He�th De�rhnec�t 1f mY ProP�Y � � � bY � �Y � � �ma[s.
� . ���e aa, a.000
� ���. �,..�._
:
PERSON COUNTY ENVIRONMENTAL HEALTH
PLEASE SEE ATTACHED PLAN FOR SOIL AREA AND SYSTEM LAYOUT
7ax Map ii: ��� Pareel q �
Zoning Township `
Applica�L_N��.%��1� � l Y`��� S�'e-rTL�) �
Locatlon:
�
�o f- a �- e ,�( .
,
Subdivision: � � ; n {- g�p�; �o� �
Improvement Permit
A buildinq permit cannot be issued with only an Imarovement Permit
New � Repair Addition Type of Strudure ��
# of Occupants iA #�of Bedrooms '-i Other
Basement? Basement Fixtures?
Water Supply �Q-{rL.
Projected Daily Flow: � g.p,d. PeRnit Valid For. CLfr`n+e Years 0 No Expiration
Proposed Wastewater System Type: 171,� m n /J ��a� rYt e.�+ �,��,�� �(1-� �re 5.
Pump Required? ✓ Yes No
Proposed Repair : ! ,.� ��� /�
Permit Conditions: tl_�1 / � / ; n �/ /�� � Q �p� ,,�. � sNll �.n�(- 0 �P i) , .
Owner or Legal
Authorized State Agent:
Date:
Date: � l��!/v
The issuance of this permitk`iy the Heafth Department in no way guarantees the issuance of other permits. 7he permit
holder is responsible for chedcing wrth appropriate goveming bodies in meeting their requirements. This site is
subject to revocation if the site plan, plat, or the intended use cfianges. The Improveme�t Permit shall not be
affected by a change in ownership of the site. This pertnit is subject to compliance with the pcovisions of the
Laws and Rules for Sewage Treatrnent and Disposal Systems of the North Carolina Administrative Code.
Authorization To Construct Wastewater Svstem (Required for Buildinq Permitl
Type of Wastewater System �q Wastewater Flow:�,�g.p.d.
Facility Type: O t�Z�G New C9�epair DExpansion ❑
Basement? O Yes ❑ No Basement F'uctures? 0 Yes 0 No
Wastewater Svstem Requirements
Septic Tank Size: _� o�J(�r` gallons Pump Tank Size: �ac� gallons
Total Trench Length: feet Maximum Trenct► Depth: inches Aggregate Depth:L in.
Maximum Soil Cover. inches Trench Separation: � Feet on Center
� .
Other.
Permit Expiration Date: _ CI - I?a - ��
Authorized State Agent: _ ���/ .�.�. Date:
The type of system pertnitted ❑ does doe ot differ from e ty
the specifications of this pertnit
OwnedLegal Representative Signature: !�"
�
.
�����o1S
�o- �i-9�
��t ��J/�i�f%1'���✓
/��'dGf�d2��5 -
' �' �2�:/�r�/ �oi✓
'•/ ��
specified on the application. I accept �$�7—
�90
'% Date: �
PCHD, rev.11/18/99
AppUcation #:
Tax Map #: =
� Parcel #: 3 �.
• Person County Health Department
Environmental Health Section
SITE SKETCH
�Q _ � �o e� S-4��- �.�'�_�c�,`n�- �� I
Applicant'� ame Subdivision/Section/Lot#
� - l.���
Authorized St e Ag nt Date
Svstem components represent approximate conlours only. The contractor must f1'ag the system
�
�
���;� _
� E-�-r2r
�
to besinnin� ihe inslallation to insure that proper grade is matntaineu.
;�y
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/���C y���� �'''�t � j�� -9 �
� �:��;2� �� �s�' °° �
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; i t,� � �
, i uc,
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_ ;
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o � �:
n � � �/� ,�� j�'vr��
� ��m
� �,�,� � �9�
Application #:
Tax Map #: 2
Parcel #• � �
• Person County Health Department
Environmental Health Section
SITE SKETCH
(�Q , � G-eo � Si�f .
Appiicant' ame
Authorized St e Ag nt
� '���`r��- Lo+- I
Subdivision/Section/Lot#
� -1��(X�
Date
Svstem components represent approximate contours only. The contractor must flag the system
u
to beQinnin� the installation to insure that proper,�rade u matntainea.
s�te: I ' � _� I �D '
PCHD, rev.1 Q112199
.. .;,.: �� � ;: ���� �� .�
��.:.•... �......
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WELL PERNIIT
PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map �� Parcel # � Tovvnslup:
Applicant: _
Subdivision:
I.ncation�
Lot # / �
Type of Water 5upply: k' Individual Community Public
Itequirements:
5ite Approved By: Liner.
Grouting Approv By: `°' � . .Installed by: .
Well Log: � Depth set:
Pump Tag: � Grouted•
Well Tag: � Date• �
Air Vent:
Hose Bib: Water Sample: �
Casing Height: 1�
Concrete Slab: �
Well Driller•
Well Approved by:
****See Attached Site Sketch****
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least ZS feet from any building foundation.
,
Other conditions:
Date: �^i�J��
f G-
PCHD rev O1/27/04
����.s.f I�.�I�.���
` '"` � � �J � � �
IE��-��-o�,..,.:,. ����Il IHI��.Il��
oa�n�r: �
Location: �
Subdivisio�:
Drilfc► I�D �. �� .., . .e ' /. � _.•
Co��i��,�n� N•,ari��� �� iI � -
--
D�t��� D��'llc��i �� �
Well Log
�,n R. � Taac Map �}� Parcel # �_
9 1� G. k �O��h� �i h.5 • �,`srcrl '�l �O'} l� -e+'1L
Lot # 1
._
Well Constrnction
Distance From nearest Praperty Line (Minimum 10 feet) _� p
Distance fiom Septic System (Mu�imum 60 feet) �o+-
Total Depth: (� u� ft Yield: 1 S�M Static Water I,evel: ft
Water Bearing Zanes: Depth�,,,��E' ft I ft ft
Gasing:
I�$pth: From __ j_� to (0 � ft. (0 3 Diameter: �� in
Type: Galvanized Steei �
'Weight: 'Thiclatess: � a Height above Cround: 1'� in
Drive Shae: v Yes No Any problems eac;ountered while setting c:asing? Yes �No
If "yes" give reasott:
Grout:
;Vrat: SancUCement
Annular Space Width
Method of Grout: Pumped �
Canerete GraveUCement
inches Water in Annulaz Space Yes _ No
Pressure Poi�red Depth to Ft.
?4lnterisls U9ed:
No. Bags Portland cement Weight af 1 Bag w� Pound�
If rraixtwe (sand, gtavel, cuttings} — Ratio to
ID plates: Yes _ I�io - 4 x� slab ____ Yes _ No
Drllling Log Locatlon Drswing
I hereby certify that the above infornnation is correci and that this well was constructed in accordance wzth regulations
set forth by fhe P�rson County ealth Degartmen�
Sign�ture of C'untracto � ID #� 7/ Date l//ra/ozi
PCHD rev Ol/16,�d�,
���y ; ,.! � ���� ��
` � � � ����
I���-a�-���.���.�:Il ]HL�.m,ll�1�
Applican
-Location
T�x M�p � P�rcel # � '-
Su�hclivision /,/_ ii , �
Phise Section Lot #
# of Bedrooms
Operation Permit
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLlNA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION.
AUTHOR ION.
. �� �-���
uthorized State Agent Date
Installed By: � < Date: /� l��
' ' � � s�rr rl
� � � h°�'""
�c�� t�
. rQ�� �,v �Oe�c
• 7PP�^�9 ��Y�`
ap��o�rtiC
��
/,
�
� �� G,��J-�✓ ov�
I Z'� `���
,� �5 ' • 3
�"��
PCHD, rev. 07/29/04
s��� r���c ������to� c����s-� �r� n- �
Tax Map-# �a�_ Parc� # � / ` � System Ty�e (Tai�ie Va) .
Owne�lAQQiicarct S�division
AddresslLocation � SeclPl�ase Lnt # � •
. .
. Se�otic i'aadt n � cation es
Stdte ID/date b � e�'�� ! t�.i/, �� z y T�encf� Width . ft. �/. L..l, w/A
Capa
Tee and Fi�er
Baffiie
Seaiar�t
� Riser ifi ap iicable'
Tank Outlet: Seai
Pem�anent Marker
. . _ - - Pump i
� `�1. ?T'r'
� �eds ValvelGate Valve . -
. . �-sip an o e . .
.� �oatsl�witches.�: . � � .
. Alarm (visab[e and audible)
Rate (gpm}
ApQroved Pump Model Ga� I c
BlocNc Undes- Pump
Pump Removai RopelChain
�Di.str�i6ution Syst,em
S'e�ial Disfibution -� �" �
_ ,
res.svre an
Low Ptessure Pipe �
Apor. Pioe Materia! and Grade
Tter7dl. D . ir� - ' ' .
Trenct� Len ft,
Trencfi Grade
Trench S acin
Roc�c D and Quai'
Da�nslSte owns etc. • �
Pressw�e� Laterals
Hole S�aang . �
o.. . . , • . . .
Pipe Steeve . � - � � � � • � .
Tum-uastProter�nrs � . . � _ � � �
� v � From Welts •. . �
� From Property lines �
� .Struc�ur�eslBasements.:: �
es ra� � e � a
. . . _ . . Surfare` Waters . . . _ .
Pubtic Water Su Ges
t/' Vertical Cuts >2 ft .
Water Llnes
(s /� � Veh�le Traffic
EasementslRi ht of 1N�
� Othe�
� Eas�meMs Recorded .
� �
Comin�nts�
�
� - pc{�d rev. 3113/01
PERSON COUNTY HEALTH DEPARTMENT
SUBSURFACE WASTEWATER SYSTEM MONITORING REPORT
2� 1 l� z� m� �.� �l
Date of Inspection System Installation Date Type Tax Map Parcel #
i�RK �-�� 1�- �
Property Address
Instructions: Check yes or no for appropriate items and explain 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. Note that this monitoring form is not totally inclusive for all systems. All maintenance
and monitoring items specified in the permit are 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 ?
YES / N
❑ �
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 t nk):�
Elapsed time readings ? LI
Counter readings ? ►1
Drawdown rate: ^'
. �
r�
■ '�
!1 ■
i� ■
.— .
r�
1i ■
►: ■
/: ■
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? �
Diversions/swales properly maintained ?
Vegetative cover maintained ? ❑
Protected from traffic/unauthorized uses ? �
Distribution devices in good condition ?
Field free of settled or low areas ? �
/
/
/
�
/
/
/
/
1�
��
i
■
t�
■
■
PRESSURE DISTRIBUTION SYSTEM:
Turnups/cleanouts/valves/taps intact &
accessible ? � � ❑
Pressure head properly adjusted ? ❑ l❑y�l �'
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
ADDITIONAL COMMENTS:
1''
■
■
REMARKS
� C,I���,P e �-'(�c.�� � f+�,,�
��'� T I✓t � u o� C¢k �f ��Ii d''l
S
�,� Yo u`r �e vt��- q l �-2�Y� �
}�-eC ov►�ri� c��'� a Y�v v�-
��•-�V`�✓� �li'1 ,�i,,�ptl,cQ'1- �✓�� o� � � �/1VL
,
C I�es+ti�,�-4- Q�- �-�-av�— D� C��a�v►-�'e (
uy� � �
.�rriql f'QiN I✓(� ,
. -� �,�_� � .
,M . .
DAVID BRANTLEY & SONS
WASi'EWATER TREATMENT INSPEC710N REPORT
SYSTEM OWNER: OPERA70R: _. . Admin,Admin.::.:`::;'_::::::;;.';`:::::':::'':::::<:;:;
Brown; Jeanne _ . . , `:: CERTIFICAT[ON: ': " _ , -
ADDRESS PIN# , .: ; ; ;::
1D4::Beechrid e'.C.ourt . ::::. °:: TAX REC: ,
,.._ ..
Cha. .ei. HiII,NC'27517 :::::::':::::`::::::::;.:::>;:::: ::':'>';;::::::: ::<.
SYSTEM OPERATOR:
DAVID::BRANTLEY;&;80NS . ,_
DATE OF THIS INSPECTION: 6L6/2Q'17. "
DATE OF I..AST INSPEC710N: 12/12/2016 ..:.:
Y N REMARKS
FACILITY:
Type, size and sewage Flow in accordance with permit X
TAP(KAGE:
Risers accessible, surtace water diverted? X ` ` `
Risers structuralf sound, waterti ht? X' `'`
Sanita tee in ood condition? Effluent filters cleaned? X
Slud e de thla earance , level acce table? ':6 "
Grease Trap: X _ :. .: .
EFFLUENT DOSING
Sludge depth/appearance , effluent appears clear?
Required pumps present, aperating, and cycling proper(y?
High-water alarm present and operating properly?
Vent/floats/pipeNalves/disconnects in good working condition?
Control panel/electrical components in good condition?
GROUND ABSORPTION FIELDS:
No evidence of effluent surtacing/reaching surtace waters?
Minimal ponding in subsurface trenches?
Surface water diverted around fields, no depressions?
Line`Cover/vegetation adequate/maintained as needed?
Protected from traffic, destructive uses7
Distribution devices accessible?
Dist�ibution devices in good condifion, working praperly?
Repair area properly reserved, maintained?
Turn-ups/cleanouts/valves intact and accessible?
No effluent standing in lawer laterals?
Laterals free of excess solids, fiushed as needed7
Diversion Ditch/Be�m in good condition?
COMMENTS•
MALFUNCTIONING
NEEDS MAINTENANCE
STRUCTURELY NON COMPLIANT
COMPLIANT
�
■
� �c�Analy�ical6
� �• mvw.pacefa6scom
ProjeG: Jamfe &own
Pace Project No.; 92354940
Sample: Effluent
Parameters
62106 cBOD, 5 day EDN
Carbonaceous BOD, 5 day
350.1 Ammonfa
Nftrogen, Ammonla
Pace Analydcal Services, LLC
6701 Conference Drive
Raleigh, NC 27607
(919)83q-4884
ANALYTICAL RESULTS
Lab ID: 92364940001 Coflected: 09/12/17 09:30 Recelved: d9/12/17 11:40 Matrix: Water
Results iJnits Repo�i L(mil DF Prepared Analyzed CAS No.
Analytical Method: SM 52108
IJO mg/L 2.0 1 09/13/1717:59 09/18l7714:20
AnalyBcal Method: EPA 350.1 1993 Rev 2.0
ND mg/L 0.'!0 1 09l23/1709:57 7664-41-7
Qual
Sampie: InFluent Lab ID: 92354940002 Collected: 0911 2/1 7 09:30 Received: 09N2/171t:40 Matrix: Water
Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual
5210B BOD, 5 day EDN Analytfcal Method: SM 52106
BOD, 5 day 80.9 mg/L 2.0 1 09l13/1716:12 09/18/17 12:50
3b1.2 Total Kjeldahl Nitrogen Analyticai Method: EPA 351.2 •
Nitrogen, KJetdahl, Totaf 76.0 mg/L 2.5 5 09/20I1710:55 7727-37-9
Date: 09/24/2617 04:45 PM
REPORi OF LABORATORY ANALYSIS
This report shaA not be feproduced, except in full,
without the wrlltan consent of Pace Malytical Services, LLC.
Page 4 of 13