A24 185_��,s� ���.���
�,_ � � ����
?�e �-Yn �-� ����.��.11 I�3C � �.11 �1�
Applicant: ►'7�6� 1'�°�
Address/Location: r ovi
S�� cr� .P.2�—'r' �
Permit Valid for: Five Years
Type of Facility: �� PP
Number of: Bedrooms � / �
Proposed Wastewater System:
Proposed Repair: �p �
�
Improvement Permit
Non-expiring �
New ZC Addition
C� / Emolovees / Seats:
Permit Conditions: S�Q S!` S�e.�2 M�
Tag Map: 2 Par el• ��
Subdivision SP+rv�'e
Phase/Section/Lot #
Vt�'ater Supply: �✓�l�
Projected Daily Flow: 36D gallons/day
Type: s __�
Type: ��_J
Authcrized State Agent: Date:
(X) Owncr or Legal Representative: Date:
� �,
The issuan�e of this pecmit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the app(ic�nt/property 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 Improvemeni is noi affected
by a change ia ownership of the property. This permit was issued ia compliance with the provisions of the Alorth Carolina �Luws
and Rules for Se►vaF� Treatment and Disnosal Svstems'(15A I�TCAC 18A .190()). Neither Person County nor the Environmental
Flealth Specialist tivarrants that :he septie s}�stem will c�ntinue to fanciion satisfactorily in the future, or ihat the water supply wiil
remair potable. _____ _ __ __ _—
Authorization to Construct Wast�water �ystem
See site plan and additional attachn:ents � �.
�
Proposed Wastewater System: �l�le�� .�c(�D ,�f'D �1`�C (*)Type �� Design Flow 3� �_ gal./day
New p� Repair_ Expansion �— �- Soil L'CfiR: . 3 D gal./day/ft2
Type of Facilit-�: 3�R�jP,P S• Basement: � Yes _ No
('`) System Typ�s IIIb, Illbg, IY, and �; require perivdic system inspections by the Ferson Counly Nealih Department.
Wastewater System Requirements
Tank Size: Septic Tar�k �df�� gal.
Drainfield: Total Area D � sq. ft.
Trench Width � ft.
Distributiou: Distribution Box
�ns:
�►uthorizzd State Agent:
Pump Tank � S 0� gal.
Total Length 30 � ft.
iVlin.Soil Cover p in.
Grease Trap �' gal.
, ,, � � �
M.A4a��-.� Trench Depth Z g i� � n'MK
Min:Trench Separation � ft.
/ Serial Distribution / Pressure Manifold X
-�- /NR�►: d7� � �s� t�t ,S�t��_�� a"�1 � �� � < < -�v?�tc,1�
Issue Date: Y-'�
Permit Expiration Date:
T'he system permitted is: Conventional /Accapted �' Alternative / Innovative . I accept the coliditions
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)
,, � r ► :
S��' � ' S� ��� �, NOTES
� C E PUMPLINE TO DRAINFIELD 8A.
� � SEE PLAT CABINET 16
42o CONTOUR \ � . PAGE 491-496 '
S87°21'S3"E S87"21'S3"E � FOR PUMPLINE DA1'A.
47.46 44 88, S86°52'23"E 137.88' \� 3"PUMPLINE INSTALLED FROM LOT �
__ _ � 15' PUMPLINE EASEMENT TO OFFSITE ORAINFIELD AND �
' ' ---- - - --- _ _ PREVIOUSLY INSPECTED BY THE
- - - - PERSON COUNTY ENVIRQNMENTAL � 's
`Pv'�e HEALTH DEPARTMENT. � � �`
-o
� 8 �o �� REFERENCE IS MADE TQ THE ���.o�\
W •,� � � RESTRICTIVE COVENANTS RECORDED r
'v'0 1• 2`5 r= �o AT DEE� BOOK 856 PAGE 428 . �'1'F � C E
r---�_ ACRES �' 3" PVC CONNECTIONS SHOWN ON \\�9\ �
� �� THE LOT AND DRAINFIELD ARE �`F`y �
� � — APPROXIMATE LOCATION ONLY. �Fy ,�0 3" PVC
� r � �i � � � � � r — — — � ��' � CONNECTION 'D�S(,(VZ.
� � � � WELLS MUST BE 50' MINIMUM SETBACK ,�� �r ' ,A
� RQ� IY �Y� � FROM ANY DRAINFIELD AREA OR SEPTIC .�� • M/� '�IAr
.
� �� DRATNFIELD �� � � PUMPLINE EASEMENT. ( �p � � "`�� �
� �
2� _�_ LOT 8 �p�i�� _� o WELLS MUST BE 10' MINIMUM SETBACK 27A ��
�° '— � — w FROM PROPERTY LINES AND 25' ►��:�
��s� S7ge22fs2"E ~��9 60�� S82°03'S0"w �p4���� � C E MINIMUM SETBACK FROM THE P�LI� � , 14A
BUILDING FOUNDATION.
� � EASEMENT �
� ��� � `.° ' CONSTRUCTION IN THE PROPOSED `r° � �
'o PROPOSED =� � BUILDING AREAS MUST MEET ALL ='- y� ._ , a
�- BUILDING .�."� '� PERSON COUNTY SETBACK REQUIREMENTS. �- 3� (0 �
AREA ��, � w ' � .- r � � � �
, ��W a
50
� 582°03 � 3" PVC o y 28 A �74 173
/.l ,/� � 1 �1 � � �' ��„ 172. 3�' CONNECTION •� r � '
�i� � 7 S w
✓ ��'� � - / / 29A �
1 (i (i � 5� g, s 1 - �
�� PROPOSED �
� 9� ``, `' WELL AREA
15'�d • p ��1" SEE NOTE .' ,,���� I NSET DETA I L
� � �
��► Q���Oa-�P dYq;��►'ti2 ���;%��,/ � MpLi�EEASE��`� DRAINFIELD
3 �� /- c,J% � -�5� P" LOT 8A
2 � �y-Pk e � O�Pr'�-� '�� , � , � - � SCALE 1 "=60'
C�A (�d Ul?✓ �`'� `� � � �
� �� �o-� i�S��( S ,-�s,,, /--
�� DRAINFIE�D DATA
�� A �
�� p�,� ��$" �r �Q/P� • � � \� � \ C.- i 57 S 17 • 03' 19 "E 35 .17'
, \ <r L-167 S40'46'34"W 15.98'
� � ��✓''i.�.�L� � �,Z� s0, i �c� �
1-1�68 S13°02'22"E 37.69'
,�t�t�5 �� / � � c� � L-169 S00"41'S9"W 33.43'
�PlL S /�,`" i � 9�' L-170 N40'46' 34"E 32.22'
� ��Q ��� ��\ L-171 S19°18'24"E 82.87'
� \ �y L-172 S02"13'55"W 56.94'
M us � � C (.-ear �y /r.tAc,r�,.��f � �_� j , �'
� � L-173 S30°04'22"W 13.25'
( � . .
��S� 1�� �. �a /QJ� i ��� / , L-174 N78 ° 42' 36"W 32 . 23'
�ae�oYe � � � �� „� �� ,
, ��� �� �����:�
/ � ':�C:�����Y
�-p � i�—SG�'Y��`l � � Q� ' ]Eaava�rm�aosa�mJl 7HL�mIl�IIa
� �� " • ��' . , '.��ITE=SH�TCH t
Nairie �o� �O� . .. . ,-- . ... . . Tas Ma # Z'�� P � � 5
ESTATE ROAD
VARIABLE
wIDTH R�W
-Si�b`� �2�'�f''� '. . Sectiaa%Lot# �el #
� - -�
Autha�ed State Ageat Date
Systeni cdmp'oxe�rts mpverene appmxinude�eanroars anly.' The eontrac�br »nist, Jlag the rystem�riar io
begrnxing ths installah'an to iRsr+r� ihdspropergrads rs tnaintarired
�`��,S.f �I�I�.���
�---�= � � ����
���n������.��.� ���.��:�
WELL PERMIT
(New � Repair _ �
Tax Map: � Parcel: � � S
Subdivision: fi?q2 1 P —SQ+�v'e
Applicant's Name: Y'�0 b�� 5=2
Mailing Address:
Phone Numbers:
Lot: �
Location ofProperty: Zr ov� �-�v�( C�' 1Qo�` —'?�`'IPSLoYu`'�Ql'' �.4 �-a�S VQ�--?
S a ,—�► S o�. —� � o� L
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 5 years from the date of issue.
4.) Issuance of a permit does not guarantee a potable water supply
Other Conditions/Comments•n
1�-P?D l��l Du-� �-t- c�- � G7r�� c �G�NS , Cu //r es, e'f��,
Permit issued by: � �"�� Date: �'- � ' �
(�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 Caunty Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Certificate of Completion
�iner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
�.��. � I��.���
= � � �T�'I["�' �e yQ�es-p��-e �
IE;�-�� ���.Jt IHL�.�Jt,EIl�. Owner:
Tax Map: �Z Parcel #: ��5 Date: —�
I.ine Tap Tap (Sch) Tap �'lo� Line �ength ]E'�oe�v /�oot
# i)aameter(in) ( m) �:. (ft)
1 � �(o Z5 dd� .IZ
2 � �� 2• 5
3 3 z- 5
4
5
6
7 -E- 2 -P.� �— d 4�
8
9
10 �
�d� ft of line x 65 gal. per 100 ft=��SOa^� ; 100 =�`�5 ga1
75°lo x�,� ga1= 1Y� gal per dose �i0 gal per minute (gpm) = I+'low itate
� � sy/'�T7 1'�.�
&'riction �ead r I,, �
I.oss: • ft per 100 ft of supply line x��� � ft of supply. line =100 =`�i - S ft f�`�-� �'
3� ft x 1.2 =�_ ft of friction head � q�� �'�' K�
Manifold Siae: 3 � ` " �orce Main �uize: � " PVC
�otal Dynamic �ead = Z�P ft of Elevation head +�- ft of Pressure head +�_ft of �
Friction Head = 33 TDH � � ��kv. �.�
Pump Requi�eanent: �_ GPM @ 3�. ft of Head �� QP�''� K•
Drawdown: l�al per dose :?al gal per inch =._� inch dra.wdown per dose
�o
C�nnea�i 19esiga �far�ation �
�: . . .., ..
PVC�sOeVatae Sd�oddedOPYCTaea 11��pw'ap
. ' P15F�W
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:.: �..:.:::.:.. �::;:::::.::::::::
.........,:,:........,....... �....
_ � : �:
� �rTanifoid 5i� / � Ta ps
�i%ld Max DTo. Taps off one side
iiza t�Ace b �x :or ta ' �oth :
�i4" t9 S 3/a" t8PS �°� '
Z" 4 �
3» ➢ �
d� �6 9
40+ � ZI � ss i
• ' F`iow er Tap
�iE ;ylc�terial Flaw GP�1
t.�" Scl:ed 30 �.�
1. •� Sc}�ed 10 i.l
;, °' Scl:ert 80 I � 1
3G �ciied s0 1= '
��y ; ��� ���� ��
�.� � � � ����
I��.�,-,�,�-�,�,�,�,. ���.�.71 IE�I��.IL�IIla
NEMA 4X Simplex Contml Panel
� -1
+�" X 4" Pressure Treated Post_ I;
Sloped To Shed Watex 12" Sepaxation
� Electrical Canduit =
�
T�x M�� P�rcel #
Suhclivision ' �' '
P1i���se Sc�ct,ion`Lot # ►
Duct SealBoth
Ezidi Of The Coz�.iit
� 24" Mininnun
,• •,
T�treaded Gate Valve •
i
. • e.• , Vmon
b" Cover • ' � AcceJs Cover • , ' . ; � 1 �
� . _ �. — '
.. • - "` ;,
• � ' � - ; • ��• • . :
�•, Opening Filled With � Zip Cozd
Anti Siphon Hole� • Ties 1
Izilet Fmm Septic Tank Portland Cement Gsrnit (Dovm Hill)
4" SCH 40 PVC Pipe � C��
, Valve
High Watex Alaxm Level
' (6" SeparatiAn�
High Level- Runp Ox -��
� � U rVapo: Lock
"' �• � Hole
. .' Dra�xdrnm �Up Hi71)
. Law Level -Puxnp Ofi --^"�
' f � �. .
�•
Concreie Riser
6" Separation
• • ' � %r ..J.'r�il' '�`�'
'�,r.rPoztland Concrete Crmut
Mutic • - '
� Ope++'� F�71ad With
Supply ' portland Cement Crrout
Lins • • '
Outlet To D'utnbution
2" SCH�OPVC Pipe
R°pe Float Wue� . � �
' Precast Concrete Tank � 4" Concsete
� � ;.; (MaterialStrex�th>350QPSI) $lock
' :•`.• ' .' ; ; • ' • . _' •, : . �: • �, : . , '.
�r
►
Fioats .:
�Rem.ovable '• •'
F1oat Tree , ;
r � • i.
: � �. � • � . �: � .
� � � �GALL�lY PUN.�' TANK
Application Date: � S � r p� 3�� �-� I�; i�� �; � Ta�c Map:
Amount Paid: �COd, O(� ����• � ��a Parcel #:
Receipt#: G 4 3�4 I�7 6d �- c.12� 1�' � 6 C�+/� ��d �
�
�� �.,�'-��,s�- I�I�I�.���T �2� ,�
)�� I `—= � cC��.�i��il e�F� s �'"�P
1Lr7lT.�S>n'7t 4D an'*•'�*T � 7th'�.aL Il �IL�I �e�+dn.11 ��Ca � � V`-� ��r
�
Application for Services (Septic Systems and Wells)
1) Service�'i�gques ed -�---
Name: 1���� ��J� J`r Phone # (home):33�' �y �,'�%��-�
Address: � `� �. , L�� (work/cell): :33 • � - � ���
�r ; n. � � o� �
2) Name and address of current owner (if different than applicant):
�lor�(� � � s�u�.�n.w� {�
Name: `'�' � m� .
Address:
3) Property Description:
� Address and/or directions to
Lot Size: Subdivision: Lot #: — �,-�• 3 �
4) Proposed Use and Type of Structure:
Residential i�. 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 apnlication must also include:
➢ A pladsite p[an of the property that shows property dimensions and the size and loca[ion 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 Couaty 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.
\ ��.- . l
Signature (Owner/Legal Representative): �-- �� Date : � � (
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)