A24 182�\��! �� � Tax Map: 2 Parcel: ���
) f �� � Subdivision Q. �PS�v-2
�_ -' ` ��-
- � � � � � � Phase/Section/Lot # S
]Cye��a���.�.-�.-T ����.Il I����.Il�I�
Permit Valid for: Five Years
Type of Facility: � �
Number of: Bedrooms /
Proposed Wastewater System;
Proposed Repair: �'c�p�
Improvement Permit
Non-expiring �
New �C Addition
/ Emplo ee / Seats:
���P� �
Water Supply: Q�
Projected Daily Flow: �U gallons/day
Type: b
Type:
Permit Conditions: S22 S��-� 5�P ��
Authorized State Agent: ' r✓�� Date:
(X) Owner or Legal Rep esentative: Date:
�
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applicanUproperty 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
a�rd Rules for SewaFe Treatment and Disnosa! Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Heaith 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: �'�C �✓ Cf►'t'1 �� •�'�)Type � Design Flow �'� ga(./day
New � Repair _ Expansion _ �Soil LTAR. , 3v gal./day/ft2
Type of Facility: ��S, Basement: �, Yes _ No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Pe�son County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank � gal. Pump Tank � gal. Grease Trap gal. ,
i� �yr✓r. `
Drainiield: Total Area / Zd0 sq. ft. Total Length ��ft. Max. Trench Depth Z���S�,.:, �i �\
J
Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold k
Specifications: r'%lyl�►�t� ZP S/ �7'� �� J�l��a.�c�� � � �QP �il{�P '� �iC'�'i.ri �C u�'Si� �—,
Authorized State Agent:
Issue Date: �� Z('� Y
Permit Expiration Date: ?�Z c�(
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)
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�iib' :n�1"�.:.�: .p -."�.� �. .. Sectioa/Lo
Authatixed Srate Agent Date
Systenrca�rp'oxants roji�erentwjiproxima�a�contours oxly.' Theeont�acJbrrnrrseflagtherystempriorio
begrtu�ing�Jrs nasiwllahbn ib iq'sn�e thaepr»pergrada is nrainta'ned �
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C- 8 11'43'12"
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WELL AREA AND
DRAINFIELD DATA
LINE BEARING DIST
L- 1 S79°47'30"W 25.00'
L- 2 N10'12'30"W 25.00'
L- 3 N79'47'30°E 25.00'
L- 4 N10°12'30"W 25.00'
L- 5 N41°30'21"W 81.78'
L- 6 N35°58'32"W 102.70'
L- 7 N43°44'03"E 39.16'
L- 8 S75°37'51"E 90.38'
L- 9 S38°53'11"E �60.85'
L- 10 S07°55'34"W 62.23'
L- 11 S35°47',33"W .50.82'
L- 12 N30'18'58!'E 54.66' TIE LINE
CURVE DATA
195.00 39.89 20.01 S87°15'36"E 39.82
NOTES
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.
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82.37'
PROPOSED
BU�LDING
AREA
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CONTOUR
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PROPOSED
� WELL AREA
��- SEE NOTE
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PUMPLINE � .
EASEMENT
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CAROLINA POWER
& LIGHT COMPANY
HYCO LAKE
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I -��ran�nu-��a�aa��ra�:�.Il IE3C��.11�l�a
WELL PERMIT
(New � Repair _ )
Tax Map:�� Parcel: �
Subdiv�sion: .Q. �P
Applicant's Name: �u � iCOSe
Mailing Address:
Phone Numbers:
Lot: S
Location of Property:
Permit Co�ditions: '
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
Permit issued by:
�New 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 Environmentai Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: Z- l'� �
Certificate of Completion
Ol,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
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IE:�.-�� ����lt 1H[�.�.11��]� Owner: "l '� IC�P�' � J
Tax Map: 2 Parcel #: (� 2- Date: I—�
I�ene T�p Tap (Sc�a) Tap �o� Line Lengt� &'�oe�v I��ot
# i�iameter(in) ( m) �;� (ft)
� z �� �� od� �v�
� �.
3
4
5
6
7 2- �
S
9
10 �
�ilio ft of line x 65 gal. per 100 ft= G v v��r ; 100 = 2iQ r� gal
75% x 2C�'�a1= l�i 5 gal per aiose 3 o gal per minute (gpm) = k'low I�ate
��u�� ����
I+'riction �ead r �
I,oss: � 7� ft per 100 ft of supply line x N� �� ft of supply.line =100 =� ft j'P�c- 'f`�'' ' Q
—�ft x 1.2 =� ft of friction head + � ,�S�i ✓� � d-�"
Manifold Size: � " Force Main Size: 2" PVC
Total Dynanuc �ead = Z Z ft of Elevation head + 2 ft of Pressure head +�ft of
Friction Head = �TDH � � �{ � ) �s �
� ���„
Pump Requi�ement: 3� GPM @ z� ft of Head� .es-�n�q �
Drawdown: ��al per dose ; 21 gal per inch =.�_ inch dra.wdown per dose
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9mmea I � 4 �
ifoid Siy / � Taps
Max No. Taps off one side
ace bv �a :or ta�ppin� �oth ;
�� 16 y �
(n 4�.f. 21 12
. . . . _ � � I`!ow er Tup
Sire �Llcu¢rial Flaw G�yl
t.;." Sclied80 �•j
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;, " .iched 80 1 � !
=�, • Sciied s0 ls = _
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I���-��-��.,�-m. ���.�.Il IHI��.Il�71�
NEMA 4X Sunplex Control Panel
+}" X 4" Pressure Treated
Sloped To Shed Watez 12" Separation
\ Electrical Cox�uit =
T�x M�� � P�rcel #
SIIhLiIVIS1011 �� �
Fh,��se'Sact�ion Lot #
�� D�ct SealBoth
� i_ Ends Of The Coz�it
�- 24" Minitraun
J• •�
Thxeaded Gate Valve •
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b" Covex • ' � Accus Cover. .� • • . ; ' 1 �
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.. , • - �"` ,y
• � '� - ; .�•. .;
. �., Openin� Filled With �. � Zip Cord
Anti Siphon Hole' ` � T�� }
Inlet From Septic Tanlc Portland Cement Cnvut (Drnvn Hill)
4" SCH 40 PVC Pipe � Check
Valve
High Water Alarm Level
' (6" Separation�
, Iii�jt Lerel- Pump On -�,��
� � � t '�Vapoz Lock
' �• � Hole
• .; Drawdown �Up Hi71)
. Law Level -Puxnp Ofi -�f
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' Precast Concrete Tank
;.; (Material Strength y35[
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4" Coz�czete
Y CYB
�SI) Black
': . :� . •. . .'� .
Concreie Riser
6" Separation
• '•� - . � :i..r;�41' -
;��PartlandConcrete Czout
. _: Mutu - - :
� Op¢ning Filled With
upply Portland Cement Graut
,ine • • '
Outlet To D'utx�rutiox
2" SCH40PVC Pipe
F1oat Wires .' �
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i
Floatt , :
�...R.emovable '•�.
F1oat Tree , ,
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O0O GAZL�N' PU� TANK
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Application Date: s� r p�f � q-� �� �� � Tax Map:
Amount Paid: • OOd , O(� ��0� • �� � � i a � � Parcel #:
Receipt#: ( y� i-4 I 7 60 �-�`# I� ��' �� / �
�1 �
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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 erniitted
❑ Mobile Home Replacement or Buiiding Addition 0 Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (1Vew/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Servic ques edb� ---
Name����� \�.�`'t•'- J`r� Phone # (home):33� [�'Lj'��L���.S�
Address: � S ��',�. Z.r� (worWcell): :33 • � - �� '
r ; n. . J�
LAIO�i�C ���/�Gul�.Wt t
2)Name and address of current owner (if different than applicant): �
Name: `'S' d mr�
Address: �
3) Property Description: Lot Size: Subdivision: Lot #: — �Jp�• 3''
Address and/or directions to Pronertv: ., �.
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 completed anplication 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' forrn 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 uaderstand 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 : ��j ��/
10/O8 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)