A24 148�aplication Date: � �J �d r��
Amount Paid: b0 . d
Receipt #:
Tax Map #: � ��
Pa�cel #: � �1" I
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APPLICATION FOR SERVICES
IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID.
1) Permit requested by: (Owner/agent/prospective owner): J�RR.y �� 5},n, psoa
HomePhone: qiQ- U7i-82b3 Address: �n�2 RYac-r�- Di4c:p
Business Phone:g�A. �7/- 7�dS-c qrq. qyy 1i�s,.c ����� �-^� r`� � Z�"7i Z
2) Name and address of current owner: C A ROl S N�1 /3 y
�i�Z I`iAR9o0 �)/U1.�
�'ru.u.l-1 �, �I. PR ti lc '� � N 7,3 f
3) Property Description: Lot size: 1a.56 Township: GvN,�..��An Subdivision: GuK Po- N� Lot #�
Directions to the property (Including road names and numbers): h s G H�s n,.�i -� D/�rN�,�n« ,� r� r�
ia�-i L��r �a n���)��,� �A,��
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed ✓, Existing _, Type of Structure: S�a It F� � �►, Width: �o � Depth: yo'
b) Number of Bedrooms: �.� Number of occupants or peop e to be served:
c) Basement: Yes , No ✓ Will 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 adjaning property? Yes_ No ✓If yes, please indicate approximate location on the
site plan.
6) Does your property contain previously identified jurisdictional wetlands? Yes_ No ✓
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED.
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT
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
faalities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid.
or Legal Re�resentative
/6 .�.�v z oe �
Date
PCHD, rev. 06/27l02
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Su!bd�ivi�siar�i % �,
Phas�e S�ction.'Lat �
� ][anpraveiaent ��rmit
P�r.mat Valid for �/�"ive �'ears lYo ��piration �
Type of Facility: �'v,z i� � e S i�ce � New _ ddition _� �ater Supp�y L,J 1 �
# of Occupants Max (� # of Be ooms 3 Frojecteci Daily Flow 3�n g.p,d.
Proposed Wastewater System: � e c� u .. ' � Type; -�
Pmposed Repair: w � • . TYPe= �
,
Permit Conditions: �I� N�a ��r� QL( c� {'�ae�s � . " :
Owner or Leg'al ]
Authorized State
c
The issuance of this pem�it by the Health Department in does not guazantee the ic��Anr.r of other p�. It is the responsib�ity of the
aPPlica�rt/proPeztY owner to in siae t3�at all Petson County Planning and Zomng and Biuiding InsPections requa�ements are met This
Ymprovement Permit is subject to revocation if the site plan; �plat'`o'r` the intended use changes. 17►e Improvement Permit is not
a�'ected by a r.�ange in owner'ship of the property. This permit was issued in complianca with the provisions of the North Carolina, .:
`Laws and Rules for Sewa.�e Treabnent and Disnosad Svstems' {15A NCAC 18A .1900). Neither Persan �ounty., moi�:tlie." �
Environmental $ealth Specialist warrant� that the septic tank �pstem w�71 continue to function satisfactorily in the futnre�or�tliaf.
the-water suPPlq w�l remain potable. • .
� Anthorizatioa to Constrnct Wastew�ter System (Required for Bnilding Permit) -
* See site plaa crnd additivnal attachments (_�. . � . :
, l
Proposed astewa#er System: . c�i � . �L aJ � ��d`�y/'pe�� Wastewatez Flow �D .p.d. �
<!' eu� �_.
New Rep '--� F�apsion _�—� � Soil LTA�iZ: ��5' g.p.dJ ft 2
Type ofFac�ity: q� r�rrho �L,����►�Ce�� � � Basement_Ye— s/t�o .
Tank Size: Septic 'Tank: � D� gai
�Vastewater Syst��n �teqiairements
Pnmp Tanlc /�do gai Grease Tray�: --�
I�rrainfield: Total Area: a/ �'o sq it Total Length � ft
Treach Width �, f� lYYinimnm Soil Cover. _� in
�ist�ibntion:
, Spe�ifications:
I3is�'bu#ion �oz Serial Distribntion
�r
State Agen� �
Permit Expiration
' 1Vla�nnm Treneh Depth LZ in
1Minimum 1i�eaici� Separation:
9 °'ft
�Pressure Manifold .
Date: 8'– /� -d �
The type of system permitted is Conventianai ✓Acc�ted�/��"7jOAlteznative. I acc�pt the specifications of the
P��-
i3�vsae�l��a1 �apr�s�ntalave: Date:
' - pCHI� rey. ll/10/�5.-:
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Name Cru�� C�ulficK � Ta.zMa.p #��Pa�::cel # ��''
Sub ' v . � Seca.on/Lot# S2,
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. 8"-�� o� �
uthorized State Agent . - Da.te �
System cnmpo�rers�ts s�e�i�esent a�roxim�cte�contours only.� The conimctor must, flag the system1brior to .
beginning the i�7staAation ta i�sure that. prolt�ergmde is mai�tairied
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Applicanf: (( �
Subdivision:
Location:
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T�pe of �a#e�-'Supp�y: �/Indiyidual _ Communi Public
tY
$tequirements:
Site Approved By:
Grouting Approved By: �
Well Log: �
Pump Tag: �
Well Tag: � '
Air Vent: � �
Aose Bib: � �
� Casing Heigh� �
Cancrete Slab: , : � ' .
Well Driller:
Well Approved by;
****�ce.Attac3aed �ate 3ketch****
0
�
Liner:
'Installed by: � .
Depth set: '
Grouted• .
Date: •
Water Sample:
Wells must be 10 feet from pmperty lines.
Wells must be 100 feet fram septic sjrstems.
Wells must be at least 25 feet from any building foundation.
Other canditions:
Date:,
PCH� r�v O1!27104
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1F�RA''S nn-•caanaan�an�E.m.�. 1HI�c�n.11�Ella pwner:
Tak Map: � Parcel #:
Date:
Line Tap Tap (Sch) Tap Flow Line Length Flow / foot
# Diameter(in) ( m) (ft)
1 � a , � �' ,
a �
3 •
4
5
6
7
8 � .
9° �
lo .3
� ft of line x 65 al. per 100 ft = ;' l 00 =� gal
75% x gal =� gal per dose � gal per minute (gpm) = Flow Rate
Friction Head - :_ '
Loss: �. 27 ft per 100 ft of supply line x��a0 ft of.supply line = 100 =�ft
ft x 1.2 =_� ft of friction head .
NIanifold Size: ��." Force Main Size: � " PVC �
Total Dynamic Head =�ft of Elevation head +�_ft of Pressure head +� ft of
Friction Head = �TDH
Pump Requirement: �� GPM @ `t �. ft of Head.
Drawdown: . ��( gal per dose ,—` 2l gal per inch = � inch drawdown per dose
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2" min
SchedIIle 4Q
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9mm�
ueeill�
1wd/mcmloQ
Size
3"
gize / r� Taps
No. Taps off one side
4 Z
9 g 3
16 9 '`
40+ 21 72
�' ' ` Flo�v er Ta �-
Si:,e lYlaterial FTotiv GP.�1
;." Sched 30 .i.�
;..' Sched �U 7.1
/ " Scl:ed 80 1 �.1
?, .. Sched 40 1 i. �
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NEMA A% Simpiex Contml Panei
�° � ��� Pnssure Trested
Slopad To Shad Waker 12' Say�ration
� Electrieal Cox�i! :
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!S" Corar • � � Acceas Cover• , , ' ' : ; � •1 � . ' i
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� e .~ Filled Wit� �
' , r , . Qp �►6 • Anti Siphon Hok' �
Inlet Fmm Soptic Tanle Po:tlaxod Cement Gzout �� g�
4" SCH 40 PVC Pipe � ' � Check
T,:� x f!ll�� i �� ,i(.� f' �i r ��,.1 # i
S u,io cl,iv i�s�i o ia /�,,. � o '
Fh���S�c.� Sc�ct,i�n Lr�t �
Duct Seal Botk
Ends Of The Coxcluit
�- 24" Mi�dnwm
,..�,..� . .
�'�re�ed Gate Yalme ;
LTnien / � n
Zip Co;
Tia�
' • � Valva �]
• High Watar Alaim Level
. , (6" Sepuation)
: j: �.,, . Hibk L�wl- Runp On
• ' : +�YapoY Lock
• '�
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. �._Drawd,own �Uy H�1). , �
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• Law Level -Pvmp OfY
� • . . Pun
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:.; ' P:ecatt Conczetn Tank ' 4" Conetei
' •�;.; Mate:ial S h a3500 PSI Hlock
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Concriie Iiisex
b" Sapaxalicn
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4,,,+._..--Poxtland Concreta Grout . .
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1 • h, - • •
• . • � Op�ning Fillad Witk
'plY , ', Portland Cement Grait •
Lina • • '
Outk! To Dists�bution
�" SCH40PVC Pipa
° ' Flost Wixa� .' �
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Float� .�:
E..ltemovabin '��.
Float Tra� , ,
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� ao0 GALL�N PIT�' TAl'�
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