A24 180_��,s� ���.���
� � ����
lCye��a���� ����ll IL� ��.Il�I�
Tax Map: � Parcel: l �d
Subdivision j�e�rv-�
Phase/Section/Lot # 3
Improvement Permit
Permit Valid for: Five Years Non-expiring �
Type of Facility: �j Ig� %�PS, New � Addition _
Number of: Bedrooms �/ Occupants Employees / Seats:
Proposed Wastewater System: �
Proposed Repair:
Water Supply: w� � �
Projected Daily Flow: 3�op ag Ilons/day
Type: ��>
Type: �
Permit Conditions: �� St`�� S��e/1�
Authorized State Agent: n
(X) Owner or Legal Representative:
Date:
Date:
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
tlie applicanbproperty 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
mid Ru[es for Sewa�e Treatment and Dunosal Svstems'(15A NCAC 18A .1900). Neither 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: � ��o2S' .� (*)Type �b � Design Flow 3� o gal./day
New � Repair _ Expans�on Soil LTAR: ��S gal./day/ftz
Type of Facility: `?���/�e S• Basement: � Yes _ No
(*) System Types Illb, IIIbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank f �(�� gal.
Drainfield: Total Area jj � sq. ft.
Trench Width � ft.
Pump Tank 1��� gal.
Total Length 32� ft.
Min.Soil Cover �_ in.
Grease Trap ^ gal.
Max. Trench Depth � 2 in.
Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �
Specifications: � 'S/'-� ��'� �
Authorized State Agent:
Issue Date: '`— [ � � `t
Permit Expiration Date: %—L�—(
The system permitted is: Conventional /Accepted �_/ Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
;
��,� s� ]��I����T
..
� �... . . . . �
: . �:. �:�:�:��� �
������� ����
I • „ �SI�=3S�TC�I =
; : �1:�,"aaie � � � ' `� S� ' . > ,.,, . - u . . .... -. Taa Map # °� �• Paxcel # «
' - . 'a1�t%` "� �• Section/Lot# 3
. . '%lis"'(�
Authaxi�ed Stdte Ageut Date � . �
� .
� Systehtcdrrp�orteAlsr�pPeaerrewjijlroxintt���oarsonly.' Theconihrclbrmart,�laSthssystempriorin
,
ibeg�'t,ining ihe mstbllaiiaa m iqs++►+e ilydtprroperg�rrde rs �raietoinad
�---
__ _ _ ___ ___ _ - -- _
� ��'a .� se�-�e�s : 1 S � �a�,�S'�� � f v � Co��k� (;vte � So ` �al�-�
�
� � ( ( - `�` 1.0 �, �, �4' \ �d � ` � l�P �--e`C01-�p� O N'\i� (/" `n � H '� e "'` +
C— 6 21°00'OS"
BUILDING AND WELL
AREA DATA
LINE
L— 1
L— 2
L— 3
L— 4
L— 5
L— 6
L— 7
L— 8
L— 9
L— 10
BEARING
N50°31'S7"E
N86'S6'26"E
S38'23'40"E
S07'02'39"E
S12°48'31"W
S44°32'22"E
S59°27'10"W
S30°32'S0°E
s5s°2���o�w
S30°32'50"E
DIST
14.70'
30.52'
67.79'
52.14'
52.93'
41.36' TIE LINE
25.00'
25:00'
2s.00�
25.00'
CURVE DATA
345.00 126.46 63.95
NOTES
420'
CONTOUR
N33'48'17"E
35.27'
S71°09'46"W 125.76
WEIIS MUST BE 50' MiNIMUM SETBACK
FROM ANY DRAINFIELD AREA OR SEPTIC
PUMPLINE EASE�IENT.
WELLS MUST BE 10' MINIMUM SETBACK
FROM PROPERTY LINES AND 25'
MINI�AUM SETBACK FROM THE
BUILDING FOUNDATION.
� —
.� —
� —
_—��
``j�� r2 l 3 � � 5
12 " �e��'
� g s� �- � c�� ��
� See �- p�— �a.� � �
/ '
� g,� �, s L,�e'Q'f�
i5'
PUMPlINE
EASEMENT
__�----
v� �___
'.—
/ ,�
�
.
��
���.sf �I��.���
�- -_-� � � ����
'�° �ra�n�c-o�n�xa��rn�<m.� ����.���a
WELL PERMIT
(New� Repair_)
Tax Map: � Par 1: —( ��–
Subdivision: 1�rE�'.5-�►��/'�
Applicant's Name: �o� }�pSsZ
Mailing Address:
Phone Numbers:
Lot: 3
Location of Property: 2� 01^ f�'V'C� C � � � '� /' � �S �L'�� S'� �S-� +� S �'�
� —� S -P `�+' c�
Permit Conditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
f I V '
Permit issued by: w� � r Date: (� �
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Certificate of Completion
Di.iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
il/26/13
������� ���� ��
�..-_
��.. ,,. �--�-� � � � � � �
I���-�.�-��.,�• ��.�.�.IL IF3I��.Il�1�
Sloped To Shed Water
b" Cover •
1
..
Inlet Fmm Septic Tank
4" SCH 40 PVC Pipe
NEMA 4X Simplex Contml Panel
x I1
4" X 4" Pressure Treated Post �
12" Sepuation
E��t�� ca�t — i
• ` Acc s Cover• •• , ' . ; � 1 ;
. � r . J
/ ' i L , . ..��• ,y , .
�,. Opex�ins Filled With Anti Siphon Hole' ,�
Poxtland Cement Graut (Down Hill)
Check
, Valve
High Watex Alarm Level
' (6" Separation�
�.,,: , . Fiigh Level- Puinp Ox -�..,_,�
� � ( rVapos Lock
' '• g, r7 Hola
• � Dxawdawxt �Up Hill)
�
. Low Level -Pump Ofi -----^'�
' ��' .
::..
' Pxecast Concrete Tank
;.; (Material Stren�th y3500 ]
�..`•.',' : ' .' •.-':
T�x M�� � F�rcol # ' �
Suhclivision ' �' • �
Pl����se Se�ction Lot #
Duct Seal Both
Ends Of The Con�iit
-� 24" Mixunwm —;
,. .,
T�readed Gate Valve
Union 1 ^� n
Zip Co,
Ties
Nylon
Rope
4" Concrete
Block
. : ' , : . . '�
Concrete Riser
b" Separatinn
• '• ' . %r,.D;61' • --"'
'�rPortland Concrete Cnaut
_ , s: Mastu • - : .
� Opening Filled With
Supply � ' portland Cement Crrout
Line • •
Outlet To Distnbutiox
2" SCH40PVC Pipe
Float Wires ' �
• •f
7
F7oat: , ;
_Removable '• •'
F1oat Tzee �
,�
r � . �.
• ' �. � � � 1 .• �. ' . .
D00 �az�or� � T�x
`��. � 1�I��.���
�- � � ���� /� 'I�/i �
IE:�.�� ����.Jl 1H[�.�.11.� Owner: V I' r`'���
Tax Map: Parcel #: � Date: —l�r �
I�ene 'd'ap Tap (Scfl�) TaQ �'lopv I.ine �,engtig �oe�vv / ��ot
# i)aameter(i�) ( m) �;. (ft)
1 z'' o ?/ 0� a � 0 g
2 ` Z'� ���� . Oc�� w 4 .
3 I �1 YO , �� �D7
4 '/Z' � �0 0 � , p
5
6
7
8 P� �- o G�
9
10 �
3 7o ft of line x 65 gal. per 100 ft= Z�(0 �--�_ ; 100 = zY o gal
75% x.�pga1= (�O gal per dose � o gal per minute (gpm) = I+'low Atate
Friction �ead r
I.oss: � ft per 100 ft of supply line x N �� ft of supply. line =100 =�_ft
�ft x 1.2 =�_ ft of friction head �
Manifold Siae: 3 "�orce Main Size: 2- " PVC
�otal Dpnamic �ead = 2 o ft of Elevation head + 2- ft of Pressure head +�ft of
Friction Head = �_TDH
i'ump Itequi�ement: � D GPM @ 2�• ft of Head �
i)ra�vdown: ��b_.gal per dose ; 21 gal per inch = •� inch dra.wdown per dose
-�� :r:.,a:� � � ����,��
, �
�� —
���a����t0 � � � �
� . . . . ,,�,. � __ �
,.. ■[t�)��0��0
-z-o-o-�-�. o-�-o-�-o-a-,-�-e-�-�-�-�-�-�-�-�-<-e-�-_-e-o-�-<-.
111 Il II 11/ ...............�..�.�.............
.. :.._ .. ... ..........._.....................
� � � � ,.:� .,_
:a :�_
�■, ='�4W � � � r
.i � K ;i i � r ' � � `-�•� �_
�.� �lII �
�'C�IIgC �
� 9maa�
�—�
side
�oth :
�es .
q� 16 9 �
se, qa.1- 2i ]2
. . . . y ' ' �`iDi� Ei TIIp
s�,E ;y��Qt FTaw GPyl
l.c �� Sc}ierl 30 .i.�
!, " Sc}1ed 10 ?.1
;i, " 5ched 80 1 � 1
j5 ' �ciied ?9 1= =
Application Date: � S � r p� �� q-� �� �� �� Tax Map:
Amount Paid: �OoCf , OC� ���d• �� 6 � i � �a � � Parcel #:
Receipt#: ( 4 3 i-4 I�1 60 �-�'-°�' �� � C�+/ �^ �
1 rp
� � ���� � f ���� �� � � 2 �4.
)�� � �' � �`'� <C���i�`� 8�-��5�� �P
��rn-s�n�c-.ca�n.+*�--�.c�ua�:an.11 7L-3C��+anll�lia �I�/(� l�-��
�
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 ❑ 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 $ I50.00 or $300.00
1) Service ques�ed � -----
Name:��E? J o`�' Jf Phone #(home):33� �%�%'%y�%��.3
Address: � `� ��„�, . L.r-c (work/celt): :�3 � - �� �
r n�. � v` O�
�lV�I"\ ��1%G1A�i/l�W��
2) Name and address of current owner (if different than applicant): �
Name: `�' � ri•r� -
Address:
:.
3) Property Description: Lot Size: Subdivision:
Address and/or directions to Propertv: _, _,
4) Proposed Use and Type of Structure:
Residential �. Business/Type: Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes %� No (wi,thCplumbing: Yes No _)
Garbage disposal: Yes No
5) Water Supply:
Private Well � (Proposed � Existing _)
Community Well: Public Water System: .
Are there wells on the adjoining properties? No _
Lat �: —�' 31
Yes '� (please show location on site plan)
Note: A compleied application 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 subsequentty 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)