A24 178Application Date: � s t� 06 _� q-� �� i�. �� Tax Map:
Amount Paid: �Oad, O(� ��D�. �� � ��a� � Parcel #:
Receipt#: ( �-} 3 �-4 I 7 60 � - �`� �� `6 /
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c� � ���.� S� I�I��.� �� �,p
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a G�p.00 �
� 11/� �/ I� Application for Services (Septic Systems and Wells)
Services
`�Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
� Mobile Home Replacement or Building Addition
$ I50.00 (if site visit required)
❑ Well Permit (New/Replacement/Repair)
$300.00/$200.00/$75.00
❑ Construction Authorization
(Fee is dependent on the type of
D Permit Revisioa
❑ Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Service ques ed�`j ----
Name:���'� "��''� J`r Phone # (home):33�` �%y'%��%��.�
Address: � 5 ��. , Z.r-c (worWcell): :33 • � - ��' 3—
r-' n.. . v` O� \
.�toY1�Q �! S�u.��.� #—
2) Name and address of current owner (if different than applicant): �
Name: `'�' G mr�
Address: �
:.
_ 3) Property Description: Lot Size: Subdivision: Lot #: – �,P�' 3�
Address and/or directions to Properlv: ., �.
4) Proposed Use and Type of Structure:
Residential �. Business/Type: Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes � No (with plumbing: Yes No _�
Garbage disposal: Yes No �i�
5) Water Suppl�:
Private Well � (Proposed� Existing _)
Community Well: Public Water System: .
Are there wells on the adjoining properties? No _
Yes '� (please show location on site plan)
Note: A comnleted application must a[so inc[ude:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing ihat the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): �-- �� Date • ��� ��/
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map: o� arc�f� : 17 �
Subdivision ,2 �P�P►�v�
Phase/Section/Lot #
Permit Valid for: Five Years
Type of Facility: �(
Number of Bedrooms / �
Proposed Wastewater System:
Proposed Repair: �
Improvement Permit
on-expiring x
New �' Addition
�., / F,mnlovees / Seats:
'D�
PermitConditions: `j2� Sc-tr�v-� Sr�1� Sx�e��
Water Supply: �'eCl
Projected Daily Flow:3 �00 gallons/day
Type: �
Type:
Authorized State Agent: �'�`2� Date: -_�
(X) Owner or Legal Repre ntative: _ Date: I
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement 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
anrl Ru[es for Sewage Treatment and Disnosal Svstems'(15A NCAC 18A .1900). 1Veither Person County nor the Environmental
Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will
remain potable
Authorization to Construct Wastewater System
See site plan and additional attachments (�.
Proposed Wastewater System: � �ppd-�C -�5� �(�`)Type� Design Flow 3�D gal./day
New �C Repair _ Expansio Soil LTAR: ,�r75 gal./day/ft2
Type of Facility: �I� 2S. Basement: � Yes _ No
(*) Systern Types IIIb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank 9(� e� gal. Pump Tank � 50 � gal
Drainfield: Total Area �9'O sq. ft. Total Length 3 3O ft.
Trench Width .3 ft. Min.Soil Cover CP in.
Distribution: Distribution Box / Serial Distribution / Pressure M
Specifications:
Grease Trap '— gal.
Max. Trench Depth � � in.
Min.Trench Separation � ft.
� S
Authorized State Agent: �'"t '�.� Issue Date: 7-�K-��
Permit Expiration Date: '7- / �{- � �
The system permitted is: Conventional /Accepted �/ Alternative Innovative . I accept the conditions
and specifications of this permit. `/ /
(X) Owner or Legal Representative: ,%� �� (�� Date: I 1 ���
�
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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IE;�-�.�� -mm ��¢�.�t �[-�C�.�.11,�7� Ownei: I n� Y�-�S?�v�2 �
Tax Map: 2 Parcel #: ��7'� Date: '7- I`1-� �f
I.ime T�p Tap (Scfla) Tap �'low Line �engi� &'�ovv /��ot
# Diameier(�) ( m) �:• (ft)
1 3 c7 0. 0 .!
2 3 �v . , � r
3 / d.� � .(I
4 %Z o ? � (�0' .lZ
5
6
7 Z ?�n + -�
8
9
10
� 3� ft of line x 65 gal. per 100 ft=� �<<S� �---'> ; 100 = z j 5 gal
75% x 2� S ga1= � gal per alose � � gal per minute (gpm) = k'low I$ate
Friction �ead �
I.oss: �_ft per 100 ft of supply line x� ��a0 ft of supply. line = 100 = 7' S ft
7• 5 ft x 1.2 =� ft of friction head
�
Manifold Siae: �_" Force Main �ize: 3 " PVC
�otal Dynamic �$ead =�ft of Elevadon head + 2 ft of Pressure head +�ft of
Friction Head = �3 TDH
Pump Requi�eanent: �0 GPM C 5�� ft of Head �
Drawdowaa: /� (�al per dose ;,23' ga.l per inch = -��` inch dra.wdown per dose
30
G�nea�al I9esign �onmaiion
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3"
� (n ( 40+
Sixa! � Tap�
No. Taps off one side
� �: :or ta i �oth sii
3/a» tap9 �°f �'
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Sis.e iLlcuerial Fla:c G�Yl
!;'� ScJied 80 �•�
�. " Scited 10 %-�
;, ,• �c1:ed 80 10,!
=, " 5ciied 40 1=•=
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��n.w-a�c-oaa�xn�aatE.�n.� �'��.m.Il��a
NEMA 4X Simylex Contml Pancl
4" X 4" Pressnre Treated Post �.i �
Sloped To Shed Water
' 12" Sep�ration
\ Elect:ical Con�it �
6" Covez••
i.'
Inlet Fmm Septic Taak
4" SC$ 40 PVC Pipe
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•' •.� ACC235 COV2!• • ' ' � ' � •j • �
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I •, 1 i =�'• . ••�`• '~ , i
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�,. Opening Filled With Anti Sipkon Ho].e'
Portland Cement Gxo�ut �� H�) �
Cl�eck
• Valve �
, Fiigkt Watex Alarm Level
(6" Sepazatiun�
High Level - Pump On �,�
;, ;: � /! �`VaposLock
Hole �
• .� Drawdrnm �Up H�1)
. •Law Level -Pump Off -�—r�
' � �' .
��
, ' Psecast Concxete Tank
� � ;•; MatexialSt:engtk>3500
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T�x M�� � P�rcel # '
Suhcllivision � ► ' • •
Ph��s�e Sc�ct�ion Lot #
Duct Seal Hoth Coxucrete Riser
Ends Of The Con�it
f. 24" Minixtnun b" Separaticn
Tlueaded Gate Valve •
Unicn .
' • � %r i.[l il � ' --"`
�„�..lPoztlazud Concrete Crmut
. - . s; MiSt]C • • - .
Zip Ccrd � � Ope„� 9 Filled With
Ties Supply � ' port]andCement Crrrnzt
Line •�
Outlet To Distnbution
;�-Nylon 2" SCH40PVC Pipe
4" Coxicxete
Float Wires < .
:• Ir
i
F7oats ,�,
�Removab1e '. : '
Float Tree ��
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r � „
.. � ; S 1 .. , ,.
'� ls� �nZ�or�� T�
PIMP ttA7ING � �
Pnmp Must ge Rated To DeLiver
' � Gallons Pe� liinute ,
Against ��Feet Of Tota.l
Dynamic pead (IDN).
a2o'
CONTOUR
SEE
HYCO LAKE
CONTOUR DATA
� so����� �� L4k�
� ST • �v
,�. S
PROPOSED Bt1ILDING ',h�o
s AREA �/�
Soe � o
� O 2N
. � oo �'o��F` t381 ° 4� �� E
v �2 1`32,47 3�� pVC
'� � CONNECTION
,o � 1 �
/2� � �y
/ o � PROPOSREA � • L 1 �� �
�/ ��� SEELNOTES ACRES ti� ��
_ �
Ngs,
138 o'Ss'%�y
�6
��
l� �K��
a��e��-�
G
�420�.
CONTOUR
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a� k o � � �h�e��5 :
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�c �Q�(S^I- �%es
� 5 r �,1�-� A ��a����
� � ' 15'
� PUMPLINE
I EASEMENT '�
LEG190 �o; P�
f ., � �
S51'43'18"E 98.44'
W r �- � ��� �
� � � � i��
Mks�- � � �
� I ��5 ►"yC�
C(�''�� sY s �✓�
� � L��� 5 �a
i�5 �((a�' �• .P
�t�e.�� � h-e re- S�ir�-�•�� l
S71°53'11"E 41.68'
N
�
N
� o
��
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�+ o
rn
7
3' PVC
SEE
DRAINFIELO
EASEMENT DATA
LEGS 190-198
` \ 15'
PUMPLINE
' EASEMENT
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. . . . ... � :�:�:���Y
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n �6� �o'S� ' . , ���I�'E SSET'CF�I C � � � �
:��T�le �/J � � Tag Ma� # � � � Paicel #
"�i'�bi`. � .. Section/I,ot#_ 1
Authosi�ed St�te,Agent � - 7 D t /�
Sysirm cabrponeAls nsplraene'a�ipmxinwfe'cmibars arly.' The cantnicMr �nastffagihe system�riarin
beg,rruirng flie buAallaifon sb i�srirrlhatpnoperg�rds is �wintained
NOTES
� PUMPLINE TO DRAINFIELD 1A. �
S�E PLAT CABINET 16
PAGE 491-496
FOR PUMPLINE DATA.
3"PUMPLINE INSTAlLED FROM LOT
•TO OFFSITE DRAINFIELD AND
PREVIOUSLY INSPECTED BY THE
PERSON COUNTY ENVIRONMENTAL.
HEALTH DEPARTMENT.
REFERENCE IS MADE TO THE
RESTRICTIVE COVENANTS RECORDED
AT DEED BOOK 856 PAGE 428.
3° PVC CONNECTIONS SHOWN ON
THE LOT AND DRAINFIELD ARE
APPROXIMATE LOCATION ONLY.
WELLS MUST BE 50' MINIMUM SETBACK
FROM ANY DRAINFIELD AREA OR SEPTIC
PUMPLINE EASEMENT.
WELLS MUST BE 10' MINIMUM SETBACK
FROM PROPERTY LINES AND.25'
MINIMUM SETBACK FROM THE
BUILDING FOUNDATION.
i
15' �
PUMPLINE
EASEMENT
i
/
ESTATE ROAD
VARIABLE
WIDTH R/W
(PRIVATE)
�
�pi i
/
/
S62°16'35"E/ �
,' 8.4s �
� �
/
` 31A
� �
I � �
w
i o � 1 1.2'
PUMPLINE
� � � 1, EASEMENT
I _ � ,, 120 _ —
rn �
3,� � ,�,�9 — — — _ --�
P��- ' s ��( � �
s�b - N � .
� � �
PUMPLINE � I� 4A f
EASEMENT �I '� �
� � /
1 00 N /
, i
I M
i 3 �
� � d-
12510 ^�
_ _ _ _ _ _ 53.� 3� _ i5' PUMPLINE EASEMENT _
N88°32'06"W 276.45 TOTAL
INSET DETAIL
DRAINFILED
LOT 1 A
SCALE 1"=60'
DRAINFIELD
�LINE BEARING
�23�qb L-118 NO3°11'24°W
�3�76;L-119 N67°32'01"E
Z6�aY L-120 S87°40'18"E
6�(,IS`,L-121 S03°44'36"W
32.$z L-122 S06"43'13°E
z3•5 ?`L-123 SO4°41'S4"W
Zl, tt �-124 S10°32'46!.W
DAT
�
12�
4::
2E
64
3�
z:
21