A24 186Application Date: j � � � p� � �� � -j I � , i �� �e� Tax Map:
Amount Paid. OOd, OU �a06. � ,��a� Parcel #:
Receipt#: � 4 3 i-1 I 7 6�0 �—�`� I� �� �
�'�� �2 �'3�0.
�� �..��� S�"_ ���.��� 8�-��S%� �P
� � � I - - : ' �—� c� � 1��i � � ) �1��2 �-�.
T�--� _s:av a v-arn ga+*-�++• ��¢:,�..11 IC�I x� �..71 �l� �
Application for Services (Septic Systems and Wells)
Services Re uested
Improvement Permit (Site Evaluatioa) ❑ Construction Authorization
$200.00/$300.00 (if > 600 d) (Fee is de endent on the ty 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 $150.00 or $300.00
1) Service ques ed ----
,
Name: �� �`j� Jf � Phone # (home): 3-3� ��% `/�����..�
Address: � `� ��, , U.r- (work/cell): �3 • _� - L�� %
r- ; n. � �` c�
2)Name and address of current owner (if different than applicant):
.AIo��� �'���Gu.��.� �
Name: `�' � �� . �
Address: �
: 3) Property Description: Lot Size: Subdivision:
Address and/or directions to Propertv: ., �.
4) Proposed Use and Type of Structure:
Residential 1�. Business/Type: Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes %� No (wit,hCptumbing: Yes No _�
Garbage disposal: Yes No
5) Water Suppl�:
Private Well � (Proposed � Existing _)
Community Well: Public Water System: .
Are there wells on the adjoining properties? No _
Lot #: — �,p�' 3 �
Yes '� (please show location on site plan)
Note: A comnleted apnlication must also include:
➢ A plat/site p[an 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/Legal Representative): �- ��` � Date • ��� �/
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
420�
CONTOUR �
SEE
HYCO LAKE
CONTOUR DATA
/ �, S��M'�
f �,_ �
/ �''`�
� �
DRAINFIELD ��
ELOT M66 T 1
� �
\ -' i ►
` ��'� � 1
C i i
� ��
\ L _'�
42U' \
CONTOUR `
� �\ �
\
------ \�
ESTATE ROAD
VARIABLE
.
� ��, — <<j �
.�a�;�
� �-�� ��P �
v��s� b.e
I i /1,� S -i- ��e.i,-�- � ►''1e5
��,��.�y �ar�.� '��
l
;,�s-�-��c4�;��.11�aY �-���P �
Y� - 5 �,-"�i�'
3" PVC
CONNECTION
P��jp�ING EpSEMEN�
�s� _ � —
15' PUMPLINE EASEMENT
18� PAVEMENT
15' PUMPLINE EASEA(ENT
�
PUMPLINE TO DRAINFIELD 9A.
SEE PLAT CABINET 16
PAGE 491-496
FOR PUMPIINE DATA.
3"PUMPIINE 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.
CONSTRUCTION IN THE PROPOSED
BUILDING AREAS MUST MEET ALL
PERSON COUNTY SETBACK REQUIREMENTS.
. �'�1y7 )� 11�: �1L �4' ���. �`I
� - � � � �:�:�:���
����.�;�m��.n. ��mn�
.,'.:��I�=SS�TCH �
� �IV�aue: �v R � . � ._ . Tax Map #�Patcel #�l.0 `�'
�'��b�,: c.� • .. Section/I,at#
. y • — —
Authoxixed State Ageat ate
Systenr cri�ponenls ro�i�erent ajipmximate�c»�Murs only.' Tha eonlfrvilor mwst,�lagihe sysfemprior to
begruningthe �'an to i�trrre ihdtpmpergmde rs nwinlained
�iL'
109
- ��NE EpSEMEM� _ '�
15 PUMP_ � - ' .�
� - �t
s�b
11A �O�p
`�3K13�o� p�Q
jOOD c- S'�
tSooJ• PT—
ZYo f�PB PS ��1
3 ` w'o�e ���5 ✓4or�e.. sa�� �J
� C
�Z,� ���� ���,
��;Su N2 -
�����d
�
13A �
�
t
CE
�� IS� u'"►�(i►nQ
�Q.�►SPn�Qw�
--�
12A
I NSET DETA�I L
DRAINFILED
LOT 9A
SCALE 1"=50'
DRAINFIELD DATA
L- 77 N84`22'37"W 55.71'
L- 78 N01"00'31"E 83.03'
L- 106 N01°22'39"W 75.97'
L- 107 N79°01'70"E 60.32'
L- 108 N25°06'00"E 17.50'
L- 109 NO2°32'16"W 8.17'
�%1�0�%B1V0
���
��`�. � l�I��.���
--- � � �T��"� 1� I�-eS� �
IE;�-�� ��¢�.Jl. 1Hl[�,�..u,e� Owner:
Tax Map: Z Parcel #: I Date: ' �
I.ene Tap Tap (Sc�a) TaQ �o� Line Length �"ioe�v / foot
# i�aameter(in) ( m) �:. ft)
1 ' 2 o S. c� ,( 3
Z �.
3
4
5
6
7
8 'Z V�P�. �i- e�
9
l.0 �
-- ft of line x 65 gal. per 100 ft= ` � ; 100 =�' gal
75°!o x Z Y � ga1= � gai per dose � S gal per minute (gpm) = A+'low I�ate
.� P��,P 1; � �
Friction �ead �
Loss: � 3 ft per 100 ft of supply line x"' � 0 0 ft of snpply.line = 100 = � ft �'e""�,�� qp��x�
�ft x 1.2 =�_ ft of friction head +
Manifold Size: �_" �orce Main Size: 3 " PVC
�otal Dynamic �ead =�ft of Elevadon head + 2 ft of Pressure head + s ft of
Friction Head = �_TDH � � � �..Q� . �-��
Pump Requi�ement: 35 GPM @� ft of Head �i �,�YJ� '
Drawdown: ��'� gal per dose ��2' gal per tnch =�`� inch dra.wdown per dose
30
C �ne�ai IHesigat �ffor��on
I.'... ,.\ .:1
tiy . , �
!����rs . , �...
�i► �i� i► i� � .
, ' ' ' �. , :._1. ,. -
2" �niu
Scbe�nHe �0
�
9m� � '�"s �
�
�
� _ � �
�
� ,: ,.
��c�»�o�oo
�iii�iiiiiiiii�iiii�ii:i�iiiii�i
►i�ai���������ii�iii�a:���i���+�
: a : �_
u%ld Max No. Taps off one side
;� (�edace b �s �or ta in �oth :
�i4" ta S 3/a" t3p9 1" �
2" '� =.
3" 9 �
qu 16 9
{�» c�a+ Z i _
� ' ' ' ' " • ' I`low er Tap
Si�e iYlcuerial FTow G�y!
t.�" Sclted 30 �.�
f, '� ScF�ed 10 7 �
;, " Scl:erl 80 I �1 !
°� � �'ci�ed ?0 1-. ;
:,
���1�� �lilJ��1./ ��
��. � �� � �1.y �J � � �
]���-a�-���� ���.�.]1 IHI��Il�II�
NEMA 4X Simplex Contml Panel
+4" X 4" Pressure Treated
Sloped To Shed Water 12" Separation
\ Electrical Conduit ^
b" Covar •
�
..
Inlet Fmm Septic Taxk
4" SCH 40 PVC Pipe '
0
, �
• ` Acceis Covez• •• , ' . ; � •1 ?
. _ �. .
o ' � '_ ; .'�`. '" . ;
�., Opening Filled With Anti Siphox Hole' \
Portland Cssnent Cnout (Dovm Hill)
Check
Valve
High Watex Alami Lavel
' (6" Separation�
, High Lerel- Pump On ,-���
� ii �Vapos Lock
. �: � _
Ho�
• .; Drawdawn �Up Hill)
. Law Level-Pump Ofi --��
' � �'
�•
Precast Concrete Tank
� ;.; (Matexial Strnngth y3500 PS
�:`•... ' , . ,.-• .
T�x M�� i - P�rcol # � �
SUh6iIVIS1011 / � �
Ph��•se Soct�ion'Lot # �
Ihut SealBoth
Ends Of The Coz�duit
-�- 24" Minimum —9
'' '� - -- -
Tiueaded Gate Valve
-- • - �
Zip Cozd
Ties t
Nylon
Rope
4" Conczete
Block
. �: • : . , �.
Concrete Riser
6" Sepuation
• '•� ' . � :�.,cf��`
'��Portland Concrete G:out
y
_ . _: Mastic • - : .
� Openi q Filled With
Supply � : portland Cement Grout
Line • • '
4utlet To Distnbution
2" SCH40PVC Pipe
Float Wire� .' �
• .r
i
F7oats ..
�Removable • •
F1oat Txee �
��
r � . �.
' �, � :` �_• '.' ..
tjOc� GALLaN PU1Vg' TA1�TK