A24 179Application Date: � s t� p� �� c� -j �� �� �� Tax Map:
Amount Paid: � OOd . C1C) ���d ��3 � �,�,� a �� Parcel #:
Receipt#: C 4 3�-} I 7 60 �- c.i�°'# IS' 16 C�+% � o-�
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Application for Services (Septic Systems and Wells)
Services Re uested
Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 if> 600 d (Fee is de endent on the e of s stem ermitted
❑ Mobile Home Replacement or Building Addition 0 Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Service+�'�gques ed�j -----
Name: a���� "�4'� J`r _ Phone #(home):3-3�' �,�'�%'%��%%�.�
Address: � `S ��. - Lr-c (worWcell): :�3 • � - �� �
r � n�. � � O�
2)Name and address of current owner (if different than applicant):
.uld�i�Q �"��S�ul�.wt �
Name: `'�' G mr�
Address: �
:.
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Property: ., �,
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 _
Lot #: —�' 31
Yes '� (please show location on site plan)
Note: A completed avnlication must also include:
➢ 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 that 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/Lega1 Representative): <.- ��' Date • ��j ���
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
. . .��,��s� ������T
:::_ � :��:���
��.��Q�;m�:�ai. ��mn�
„ :�SITE`_ �:SSETCH ' �
; Naale : � ' \'�� • . Tax Map #�Pa�cel #�
"-�,�'� �. ,,- • .• Section/Lot# 2
'w► ���7-�
Authoxized Stats � t � Da e �
Systemc6�rporrelrrss�p�'erentappivxin�ate�cmroursonly.' TheeanihrclormwssfJagtherystempriorto
begrnning fhe iru7allahbn to irtsr+ne thaepnopergntde rs nraintained
-- � �- oQ� s�,.6 �o� 1 �3 U�►-a� � � PC� � sP��-�- a►--.�-� .
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TOTAL
TOTAL
TOTAL
SEE
HYCO LAKE
CONTOUR DATA�
420'
CONTOUR
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1 qKe"
� iS
0
��o �F
- c
PROPOSED �
BUILDING
AREA
1
.
3 ��
SEE
HYCO LAKE ,�p ��l�
CONTOUR DATA � 6
�
\
� � Re� r F�
PROPOSED
WELL AREA
- SEE NOTE
r- LEG 15
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o,
� `��
A
��so
. � F
\\ � L T 2 a .�' .�
� DRAINFIELD F,�
\� � 4
�
LEG190
15' �PUMPLINE� � `
EASEMENT �
S51°43'18"E 98.44'
S71°53'11"E 41.68'
S71°53'11"E 70.57'-J �
,
.
BUILDING AND WELL
AREA DATA
LINE BEARING DIST
L- 14 N58°58'47"E 25.00'
L- 15 S30°32'S0"E 25.00'
L- 16 N58°58'47"E 25.00'
L- 17 S30°32'S0"E 25.00' �
L- 18 N58'S8'47"E 108.90'
L- 19 N08°48'42"W 27.00' TIE LINE
15'
PUMPLINE
EASEMENT
1� �'/ _-
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� � s
' / �
/ 3" PVC
� CONNECTION
� ESTATE ROAD
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NOTES
PUMPLINE TO DRAINFIEID 2A.
SEE 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 8EPTIC
• PUMPLINE EASEMENT.
WELLS MUST BE 10' MINIMUM SETBACK
FROM PROPERTY LINES AND 25'
MINIMUM SETBACK FROM THE
BUILDING FOUNDATION.
0
PROPOSED SITE PI
��� �� ���
AT HYC � LAI�
CUNNINGHAM TWP., PERSON t
HAMLETT—JENNINGS & ASSOC]
212 S. LAMAR STREET, RO)
DECEMBER 2013, NEAL C. HAI
100 p 50 t00 ypp
I I I. I �
8AR GRAPNI inch = 100 ft,
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� 6A �
� � 28A
30A �
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CE '
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INSET DETAIL
DRAINFILED
LOT 2A
SCALE 1"=60'
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29A
--v— — —
NE EASEMEN7 - -
N88°25'41"W - - - - - - - - -
3" PVC
CONNECTION
2A DRAINFIELD DATA
L-144 S13•05'45"W 35.89'
L-149 N88'25'15"W 19.94'
L-150 N80"12'S5"W 43.25'
L-151 S73'32'43"E 21.25'
L-152 S28°22'42"W 60.25'
L-153 N88'25'41"W 69.46'
L-154 N13•05�45°F 30.87�
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T�x M�� � P�,rc�-e.l #
Suhclivision ' ��' ' '
Ph��se Sc�ctionLot #
NEMA 4X Sunplex Contml Panel �
x �� Duct Seal Both
4" X 4" Pressure Treated Post j Ends Of The Cozubuit Concreie Risex �
Sloped To Shed Water 12° Saparation 24 Minitmim
u
� Electrical Cos�t�it ^ " '' ' � ' ' ' ' ' b�� Sepuation .
Threaded Gate Val�*e •
, ,, , • ,.. .
ilnion , • �! r
b" Cover • ' � Acceas Cover. � • • , ; ' .1 ' '��.Poztiand Cox�creta Gxaut •
' , . , i . _ - .. '�._ : ' , _: Mutu • - •
• � � - , . �• . . , . , _ _ .
'�� O e � Filied With � ' Zip Cozd , � Opening Filled �th
r.• P�S Anti Siphon Hole' •'p�s Supply �.� portland Cement Gmat
Inlet From Septic Tank Portland Cement Gmut �� g�� � L�¢ ••`
4" SCH 40 PVC Pipe � Outlet To D'utribation
Check .�.�Y�n 2 SCH40PVC Pipe
, Valve �Pe F1oat Wizef ' �
High Watex Alarm Level ; '
' (6" Separation� .�
. High Lev�el - Pump On i�
� � ! � rVapos Lock Floats ..
�• �Cj Hole � � ..
• � Drawdawn �Up Hi11) � �Removable '. •' �mp �� �
� ' �F Float Tree � �
. Law Level -Pump Ofi � ,
. � . Puntp .
, . S Pxecast Concrete Tax�k 4" Concrete - - ' . �� �
� ;.; (MatezialStrength>3500PSI) B1ock ' I ' ��
, ,�t'. • '' ' • j � • • ' ` • . . •+ � • • . • �\ • ' \ ' S . � • • •,• �
����GALL�N FITMP TANK rv � 5 c�� �
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�- � � �T�T�`Y �� 1��e �ew� �� 2
IE:����� � ��i��.11 IHL�.�..11,�. Owner:
Tax Map: 2 ParceI #: Date: / 7—�
I,ane Tap Tap (Sch) Tap �'+'lopv Line �ength �odv /��ot
# iiiatneter(in) ( m �' • (ft)
� � z t� . I � D' i�
2 �.
3
4
5
6
7
g 2 �
9
10 �
r--- _ o—
r-�` ga1= � gal per dose 3�per minute (gpm) _]H'low Rate
��el� ,c �. s � p�,� p ����
E+'riction Aead �
I,oss: , L%i1" ft per 100 ft o_f supply line x� ��v� ft of supply.line =100 =�� ft „QS-�i°►�t.4 �
�f S ft x 1.2 = T ft of friction head � �
Manifold Siae: �" Force Main �ize: .3 " PVC
�otal Dynamic �ead =�ft of Elevation head + 2 ft of Pressure head +�ft of
Friction Head = 5� TDH ��- �..� v, �,..��
Pump Atequirement: 7g GPM @��• ft of Head �r � S/;,�-ia �ca�
Drawdowaa: �(a S gal per dose �1 gal per inch = 5• 5 inch dra.wdown per dose
3��a��
�ea si IB� �for�a�ion .
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Sia.e �1lat¢rial Flow GPyl
t.�" Sclied 80 �•j
!," Sched 10 f•�
,g ,• �c1:ed 80 I �1 1
jG ' �'Ci1ed �0 1: ;