A23 84� • � d J� �-�3
Application Date: ��6 ��'Z � � A�J • �Q � Tax Map #:
Amount �aid: ��� `1 ��� �
Reczipt �: 2 6i� � d rarczl �:
S��'�s�s
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APPLlCAi'ION FOR SERVIC�S
IF THE IMFORMATIOfd IN THE APP�ICATIOiV FOR AN IMPROVEMENT PERMIT IS IIdCORREC�, FALSIFIED,
CHANGED �R ZHE SITE IS ALT'ERED. THE� THE 1MPROVEiIAEFVT PERMIT_AND AUTHORIZA►TI�N TO
CONSTRUCT SHALL BECOME INVALID,
1) Permit requested by: (Ownerlagent/prospective owner): �f�/�/� /�� L-% v�F3C- �5?R/�
Home Phone: Address:
Business Phone: ,�"9�- 6S�
2) IVame and address of current owner. S7eUc? Xa7� iIJPCJOY�N� � �/ �e s%�d��11%
//� S' /fla:�.l ST
' /�o�C�o� /(�G
� Townshi W�N�� "_ �ubdivision: �/i-/� �T Lot #�
3) Property Description: Lot size: p:
Directions to the property (including road names and nur� bers :
�1 c G/i e e s'�i• // /1,0 �"a !� C, i^. /.r'T� _!J�'a.� Pl
4) Proposed Use an tructure Description: answer each of e foJ lowing questions: �
a) Proposed , Existing Type of Structure:'S�f o �/f Width:� Depth� -
b) Number of Bedrooms: � Number of occupants or people to be served:
c) Basement: YesJ No f/ I�Vill there be plumbing in the basement?
d) Garbage Disposal: Yes , No �
5) Water Supply Type: Private ��new'� or existing�, Public , Community , Spring _
Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the
site plan.
6) Does your properly contain_previously identified jurisdictional wetlands? Yes_ No�
PLEASE IVOTE TiiE FOLLOWING:
� A PLAT OF THE PROPEftTY OR SITE PLe�►N iV1UST BE SUBMITTED WITH THIS APPLICATI�N.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE ST.4KED aR FLAGGE�.
9 THE SITE MUST BE READILY ACCESSIBL� FOR AN EVALUATION BY THE liE.a►LTH DEPARTMEPIT
STAFF.
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
facilities to be placed on the prop understand if the site is altered or the intended use changes, the permii shall
become invalid. � �
/i��� ��� o � � Z
Date
PCH�, rev. 06l27/02
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1��d-a���-�.-;,-r ����.]1 IE���.Il�I�a.
Applicant:
Location:
�
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T�x M�� I � P��rcel # d•
S�ubclivis�ion �i, �r
Fh�s�e Sect+ion�Lot #
Improvement Permit
Permit Valid for �ive Years No Expiration
Type of Facility: __�' i2 ,�' �,u,; ,�, �s%��-�� New �Addition
# of Occupants �_ # o edroo Projected Daily low
Proposed Wastewater System: � ' ��o �c.t. �
Proposed Repair: e ' ' ��-
�i'i v�.�.e
Water Supply �
g.p.d.
Type: ��_
Type: � =
Owner or Legal Representative Signature:
Authorized State Agent: �
Date: !j `-��`6
Date: �--��, -p �
The issuance of this permit by the Health Department in does not guarantee the issuance of other pemiits. It is the responsibiliry of the
applicanbproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorilp in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�. C�� ���'""�
Proposed Wastewater System: �JCZ Typ�� Wastewater Flow ��.p.d.
New � Repair Expansio + � Soil LTAR: � a g.p.d./ ft 2
Type �f Facility: �g� ��' • Basement _ Yes _ No '
� � Wastewater System Requirements
Tank Size: Septic Tank: ��JC� gal Pump Tank: Q o 0 gal , Grease Trap: gal
Drainfield: Tota1 Area: �_ sq ft Total Length D O ft Maa�imum Trench Depth �� in
Trench Width _� ft Minimum Soil Cover: �D in Minimum Trench Separation: g ft(9'C•
Distribution: Distribution Box Serial Distribution 1� Pressure Manifold
Specifications: � L%►� � S `e S�e Qi� ( '� ilc�� vllP<<5 l(? f bi�- p G �� [
o�� 6lc�v. �,��M S. rtia��c l-�1� 5ro `�,,v�. SP�-I�a.�K a,�-, aKP �
Authorized State Agent: --�
Permit Expiranon Date:
-v
Date: �-2 -t� �
The type of system permitted is onventional D� Innovative Alternative. I accept the specifications of
the permit. %�� r�j t�
Owner/Legal Representative: � '"' /v� Date: �� %2�^� l
PCHD 1/17/2003
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SI'i'�. SSE'rCH � �
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Name �e � �r� Tax Map # ��3 .Paxcel #.�_
Sub ' ion � a���� � Section/Lot# �
� v�� . � z �
� Authorized State Agent � Date
System co�nponents represent appro.a�imate�contours only. The contractor mustflag the systemprior to
beginning the installation to insure thatpropergrade is maintained ,.
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1�iEMA $Z Simplex Co�svlPmal
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4" X#" Pms� Tz�ated Post - j End� Of Tl�a Condmi Coac:ai. � .
. • S3opad To SIud Wat� 12" S�pazatioa a4■ ��• .
. � Eleetrical Co�t ^ , . . � • , , . 6" S�p�ion
'T��, Gat�a Vatva •
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a° Coo�r •� ' • . , • ' Post),.�d Caars.t. C�ont .
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, �IIti $ip�Ori �O}R � jg� "`�'�"r • • •• P02�i9� � Ci200t
• pOZtliIId � � � • • � .
Inlet Fmm Saptie Ta�k (Down H�lj .
d° SC8 40 P9C Papa � �� �� Zo° $�CH40P�C�
�alvs �Pe P7wt Vq'm� � :
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Ho1e �
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� Float Txh , • ,,,,�,
. � Loa� Lavsl-Pmap O$' � . �� -�"✓ L � ` .
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� � : ' P:eca�t Concrate Taak 4' ��� • " ,
•� ivml S }3500 P Hl�c]c ��� � .:•
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IE�.-���` �e�a�mll ]HI�.�.11,�]Fa Owner: �M�j / � ll ►�1
Tax Map: �`T �3 Parcel #: Date: ��
I.ine Tap Tap (Sch) Tap �'!ow Line Length �'iow / foot
# Diameter(in) ( m) � : • ft)
1 2�� sc� � 7. J6� ,c�`�
2 � �.�' ��0 2� I � �v�
3 2 c� � f?-� , �7 7
4
5
6
7
8
9
10 �
� ft of line x 65 al. per 100 ft=� Z� _l¢s�� ; 100 = lg�gal
75% x l� ga1= � gal per dose _�� j _ gal per minute ( g pm) _�+'low Itate
Frictio H d
I.oss: �� � ft per 100 ft of supply line x� b v ft of supply. line ; 100 =�' 7 ft
� ft x 1.2 =�• / ft of fricrion head �.
Manifold Size: �_" ]Force Main Size: Z" PVC
Total Dynamic �iea � ft of Elevation head�� ft of Pressure head + 2 ft of
Friction Head = �`�TDH
Pump Requirement: � GPM @� ft of Head
Drawdown: J� per dose : 21 gal per inch =�_ inch drawdown per dose
G�teral De.dgn Information
�: . . ..,
PV+C Li+ls Vaive Sdrdde� Tas 1lmrup �aP ,
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r�1��.�:����.���l������.�.�:�.��i�*�:�.r
:� v:
M�z Na Taps off one sfde
nce bv 1/s for ta»Din� both ;
3"
6» � au+ � a i � ,.. —1
� � � � � � ' �'low er Ta
Size �Llaterial Flaw GP3�1
c4" Sched 80 3•3
. !_ " Scl�ed 10 7-i
s, " �ched 80 1 � 1
;, ,• Sched 40 IZ..S
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SEPTIG T�efVK INS���'�'i�Pl�CC�E�Ki:.lSi CTyPe II - IV�
Tax Map #,�� Parce! # o System Type (Table Va)
Owner/Applicant Subdivision
Address/Location Sec/Phase Lot #
- Sep#ic Zank nitial/ ate �tr� icat�on ines roet�a aie
State 1D/date�; g � � � -� �-o � Trench �dth ft. `� �
Ca aci � �oo al. � Trench De th ti in.
Tee a.nd Fiiter T.renctt Len th vD� ft.
• Baffle Trench Grade � �
Sealant Trench S acin
Riser if a licable � Rock De th and Quaii
Tank Outlet Seal Dams/Ste downs etc.
Permanent Marker � Pressure Laterals �
. Pump Tank Hole Spacing
State ate �-z.o-o o e ize
� Ca aci ioo o ai. Pi e. Sleeve
Wate roof /Sealant Tum-u s/Protectors
Riser Required� Setbacics
Water Ti ht From Wells �
Pump From Property lines �
Checic Valve/Gate Valve Structures/Basements
Anti-s�p on o e itc es rainage ays
Alarm visable and audible
Electricai Com onents �
Rate m
A roved Pum Mode! � oS� i-
Block Under Pum
Pum Removai Ro e/Chain
��Distribution. System
Serial Distribution
ressure ani o ,
Low Pressure Pi e
A r. Pi e�laterial. and Grade �
Valves
Surface Waters
Public Water Suppiies,
Verticai Cuts (>2 ft.) �
Water Lines
Vehicle Traffic
EasementsJRight.of V'
Other�
Easements Recorded
e e perator o�
Tri-Partate Aqreemen
Comments
pct�d rev. 3/13/01
'JJ.�..i aV�i•1 IU.V. I.�t ,
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� � �v f�".�]-� � � � ��•: � � � K S
C� � � �. b o s� __
4i�ell Log � .
Owner: �-rn.� r___,_%� Tax \,Zap �,�3 Parcei # ��
Location: �,�� e � �-
S.ubdivision: Lot # ��
. . ��'ei! Construction
. Distance From aea�e:��t Property Line (?�finimum 10 feet�
Distance frocn Septic System (Minimum 60 feet)
Total Depth: �� .ft Yield: � GFM Static Water Levei: � fi�
Water Hegrin g Zoncs; De pth,�/,�.ft _ f�ft f� ft . _
� Cxsing: : � .
Deptfi: Frorn _Q__ to �-.3 • ft. Digmc�t�r: G i in
Type:.Galvanized Steel _/� —� � '
Weight: _�_yThick�.ess: _��F� �, Hei�ht s►�ove Ground: �j '� in
Drive Shoe: v� �� No A.ny pcohl�ns encountered whiie setrinb casing? Yes �-�Fe
.If `�es" give reason: _ �
Grout:: ,
Neat:. � 5and/Cement � Conc�cte GraveUCement �
� . Aanula* Space W�dtb �'� inches � Water in tlnnulax Spuce Yes �o
Method �>f Grout: Pump�d Pressure �ou,md Depth D to 1-a _ Ft.
Materigls G'secl:. �
� No. Bay,s Portland ceuient � Weight of 1.Bag � 5° Pounds
If m�izture (� d,gravel, cuttings) — Ratio 3-- to 1 �� ..
� ID plates- _�es _ Iv'o 4 x 4 siab .� No •
. Drilling I.og Locictiun Drawin�
I hereby certify tbat tr.e above information is correct and that.this wcll was cons�:cted in occordunce••Niifi regulations.
set forth by the Pe:saii Count} Heal Depart�nent.
� Signature of Contr�i�.tor LD #„�- 0 3 t Late ���" °�
PCF�D rev O1/16ip2