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Tax Map: 2 Par el: ��
Subdivision
Phase/Sectio ot #
Permit Valid for: Five Y
Type of Facility: 3.�12
Number of: Bedrooms �
Proposed Wastewater Sys
Proposed Repair: �
Improvement Permit
Non-expiring �
S� New � Addition
;cupants / Employees / Seats:
Permit Conditions: � �'i`� ��'��1.1
Water Supply: W � l �
Projected Daily Flow: 36c� gallons/day
Type������
Type•
Authorized State Agent: /��N-� 4 ���"'�� Date:
(X) Owner or Legal Representative: Date:
The issuance of this permit by the Health Uepartment does not guarantee the issuance of other required permits. It is the responsibility of
the applicandproperty 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�:rl Rules for Sewage Treatment and Disnosal 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: �'�s �l P m D (*)Typ�� �- Design Flow 3�� gal./day
New� Repair _ Expansion Soii LTAR: . 3 o gal./day/ft2
Type of Facility: ✓� � S. Basement: � Yes _ No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by ihe Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tar�k ���� gai. "' Pump Tank �� gal. Grease Trap _ gal.
Drainfield: Total Area �DO��i sq. ft. Total Length ad � ft. Max. Trench Depth �� in.
�Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation _ g' ft.
Distribution: Distribution Box / Serial Distribution . / Pressure Manifold �
Specifications: � � c��,C�t l�� �'i-�, � �P p��P ��'(� �..� � S�'\`�'+ �L-�-e'�f
Authorized State Agent: Issue Date: ?— Z�[ S
Permit Expiration Date: 2 2�Z�
�a����
The system permitted is: Conventional �/Accepted / Alternative / Innovative . I accep t t he con di tions
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)
PUMPLINE TO DRAIN�IELD 16A
SEE PLAT CABINET 76
PAGE 491-496
FOR PUMPLINE DATA.
3"PUMPLINE INSTALLED FROM LOT
TO OFFSITE DRAINFIELD AND
PREVIOUSLY INSPECTED BY THE
PERSON COUNTY ENVIRQNMENTAL
HEALTH DEPARTMENT.
REFERENCE IS MADE TO THE
RESTRICTIVE COVENANTS RECORDED
AT DEEp B00K 856 PAGE 428.
3" PVC CONNECTIDNS SHOWN ON
TNE LOT AND DRAINFIELD ARE
APPROXIMATE LOCATION ONLY.
WELLS MUST BE 50' MINIMUM SETBACK
FROM ANY DRAINFIELD AREA OR SEPTIC
PUMPLINE EASEMENT.
WELLS MU$T BE 10' MINIMUM SETBACK
FROM PROPERTY LINES AND 25'
MINIMUM SETBACK FROM THE
BUILDING FOUNDATION.
CONSTRUCTTON IN THE PROPOSED
BUILDING AREAS MUST MEET ALL
PERSON COUNTY SETBACK REQUIREMENTS.
�
i
1
18A
3" PVC
�SSur-�- CONNECT ION / /
,/� . � �/ ��
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19 A � � � EASEMENT
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15' PUMPLINE EASEMENT _ _ I _ _ —
._L_
"PINESBOROUGH ESTATE"
INSET DETAIL
DRAINFIELD
17A
SCALE 1"=60'=
DRAINFIELD DATA
L-203 S86°11'42"W 52.00'
L-205 S14°51'01"E 60.39'
L-206 S02°30'S3"E 77:86'
L-207 N88°37'40"W 62.69'
L-208 NO3°32'19"W 131.45'
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' 2 2-15
tluthoxized State Agent � Date
Systen� co�mrer�is �iveaent aji1bmximate�croniours only.' The contnic�hr mw�t,�lag the sysremprrar to
6egrt�ning iJrs a+s7rrllahbn to iq:i�re fhdepropergrrrile rs nwinrairad
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Tax Map: � Parcel: � g �
Subdivision: �� �p$kLv-Q
Applicant's Name: �i� �S�
Mailing Address:
Phone Nurabers:
WELL PERNIIT
(New� Repair_)
Lot: �
Location of Property: S1� �T �� v� �S-� -�e i��t' • � �`�` d `� �
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 permiF does not guarantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�1ew 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:
AdditioHal Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: 2 Z — � �7
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
11/26/13
rvcr�v�
I�rm9m�t
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--- � � �T��I'� �� 1��Se,.ve �7
lE;�-�� ����.v. ]HI�,�.u,E� Owne :
Tax Map: Z Parcel #: Date: 'Z-Z� I S
�,ine 'I'�p Tap (Scfla) Tap �'lo� Lirae �.eng#h &'�odv I ��ot
# Diaaneier(�) ( m) � ;. (ft)
1 3/ �� /? 5 0-0 • I Z 5
� 3 �(o � Z- S uY� . l2 5
3
4
5
� Z vt r
%
g
9
10
N`� ft of line x 65 al. per 100 ft= h°� � q =100 =� gal
75% x Z� ga1= ��D ga1 per dose 3O gal per minute (gpm) = I'low IBate
Friction �ead ?� �%Ur�, ���
I.oss: � 2 ft per 100 ft of supply line x N i�'d0 ft of supply.line = 100 =�_ft
�� S K�z
_�_ ft x 1.2 = � ft of friction head
a ��X
11�Ianifold Size: 3� " Force 1Vlain Size: � " PVC
�otal I3ynamic �ead = Sc� ft of Elevadon head + 2- ft of Pressure head +� ft of
Friction Head = �TDH
Pump Requi�eanent: 3 � GPM @� ft of Head �� ��� �
Drawdown: �_gal per dose �rgal per inch = S uich dra.wdown per dose
30 ,���x.
�ea�sl I9esigat �'or�ation ,
�� :.. ... ..
Se�eddeAOPVCTaes 11mm��padwp _.
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a y:
l�Iani%id Siz.: I� Ta s
u%ld Max No. Taps off ane
;ize (.'irdnce b �/s :or ia in r
�i4» ta s '/a» taps
2" 4 �
3" g �
d� 16 9
4U+ � 2i � iZ 1
� �"low er'iap
Siue illtuerial Flo:t� G�Yl
!: " Sched 80 �•�
�." Sctied10 %.�
;, " .:�cl:ed 80 1 � 1
�• � Sciieri 40 : " '
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y � � � ����
I��.�-a��������.Il IHI � �Il,�IIa
Sloped To Slied Wates
6" Cover �.
..�
Inlet Frorn Septis Tank
A" SCH 40 PVC Pipe
NEMA 4X Simpiex Control Panel
4" X 4" Pxessnre Tzeated
12" Separation
Electrical Cox�it =
�
�s �
• ` Access Cover• � .• ' ' �. ' •1 � ;
. • ..
.. - ' ' �. � '
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�' ' � � �
�,. Opening Filled With . Az�ti Siphon Hole' \
Portland Cemsnt Gxaut � �
— � �
Check
• Valve
, FIigh. Watex Alarrn Level
(6" Separation�
Higlt Level - Pump Ox ���
, ;: � � t � rVapor Lock
Hole
• .� Dra�xd,o�m �Up H�71)
•Low Level -Pump Off --�-'
' Pr�cast Concrete Tastk
;•; MaterialStrengtk}3500
. . ., .
� ,�`'' • ' • • � -
/
T�x M��� F�rcel #
Sulacllivision • (�•`� -
Ph���s�e Sect�ioii Lot #
Duct SealHoth
Ends Of The Conduit
-` 24" Mix�iixttnun —i
" '' - ---- -
Threaded Gate Valv�e
� _. r
Zip Co:
Ties
4" Coxuiete
�SIj Block
':. :'. �, • ,�.
Concrete Riser
6" Separatien
' • .' � %r..r!%J' -
;�,,,:.r-Poxt].and Concrete Gzout
Mastu � • - •
� OpeningFilled With
Supply � ' � portland Cement Crrout
y� ..
4utlet To Distnbuti�ox
2" SCH40PVC Pive
1e E7eat Wixes . � �
f
i
FJoats . ,
�,..Removable .:
F1oat Tree ��
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� 15v� G�s..a�v�r�vrn T�vx
� ':.
PtiMP EtATING � .
Pump Hus ge Rated To Deliver
�30 Ga11oRs Per Hinate,
Against _ 5? Feet Of Tota.l
Dynataic Head (IDN) .
Application Date: � s t I� p� N� �.� j� ���Ce Tax Map:
Amount Paid: OQO , Ov aa00. �3 6� i��A� � Pazcel #:
Receipt#: 3 I GSO �- c.l2�kk I.� i G�,l o-�
1
� r2 ��a�
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1F�`-�cav�a�-xaan�--�-�.�aa�.a�.7L IC�c� w.Il�lEa ,Il/j,'� �-/''•
�
Application for Services (Septic Systerns and Wells)
1) SName� \s �f��d "oSt' J f Phone # (home): �3�' �/'l/ `���%��.�
Address: �`S �, L�' (work/cell): :�3 � �' t'3
' '� o�
r , n. ,
J�O�� ����o�nl�•w� 1
2)Name and address of current owner (if different thaq applicant): �
Name: S' � m� �
Address: •
3) Property Description:
Lot Size: Subdivision:
Lot #: l �� 31
4) Proposed Use and Type of Structure:
Residential 1� Business/Type: Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes %� No (wi�plumbing: Yes No _�
Gazbage disposal: Yes No
5) Water SupplY:
Private Well � (Proposed � Existing _)
Community Well: P.ublic Water System:
Are there wells on the adjoining properties? No Yes 'I� (please show location on site ptan)
Note: A comnleted aan[ication must also include:
➢ A plat/site plan of the property that shows properly dimensions a�d the size and location of all
proposed structures. �
➢ A signed copy of the `Lo1 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 : l� � � �/
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)