A24 195Taz Map � Parcel # j Q�
�1��� S f ���� �� Subdivision � .�
�.. �!" � � � �- � � Phase/Section/Lot # 1
]��.�aa-� ������.Il IE3L � �,Il�77�
# of Bedrooms 3
Applicant: �� /'�s�
Location:
h o S �
Operation Permit
System Type (Fram Table Va): Product (IIIg): �p'"���
Type V& VI Expiration Date: Type V& VI Renewal Date: I� % O(
T
This system has been installed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction
Authorization.
(Authorized Agent)
� ���
(Licensed Contractor)
S�A �G a�l
t� � Ca� �
Po.-'r
Qovk �
, � �S
1�
Scale 0 �
PC�iD,rev.12/14/12
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5z � la kR
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(Date)
1rr���
�,� (Date) �
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Tax Map: Pa; cel #:
Septic Tank System Checklist (Type II-I� System Type: ��t S��'���
Se tp ic Tank nitiaUDate
State ID & Date: --� 11- fo
sr3 ►�t2 v�
Capacity: f o 0 0
Tee and filter ✓�
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set)
Serial
Pressure Manifold
LPP
Notes•
� Nitrification Lines InitiaUDate
Trench Width: �� ft. 1 F-
Trench De th: 3 o in. �
Total Length; '3 o-o ft. c�
Minimum s acing: ft. ✓
Rock de th/ uality �
Dams/ste downs
Grade (< .25" in 10') �/'
Cover (6" minimum) t�'
Setbacks
From wells
Pro erty lines t/'
Foundations/basements
SurfaceWater �
Other: '
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date: _ . � (
PT" r� �
Ca acity: ? s- �
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Hard wired
Alarm functioning
Mounted on ost
Above grade (12")
Conduit sealed
Pressure Mani%Id
Number of taps: "� _
Size and sch: Sc� ti
Contracted Certified Operator (Type IV Systems):
Notes:
W�s
i�
Tank Com onents InitiaUDate
Pum model: �IG�P� (g'g' (-
Block (4") �
Nylon retrieval ro e �
Float tree and attachments (/
On/Off float swing: in. ✓
Alarm float (6" separation)
Anti-si hon hole ✓�
Check valve �
Threaded union �
Gate valve �
Conduit sealed
Outlet sealed
A proved and secured riser
S� I Line /l�
Size and material: in. y�sch. ��- �
Length: � � Q o c� ' ft. ✓
w
- .�,�. s� �'��.� ���
- - _ �— .{� � � ����
7�'s�.�u-��-�.-„-„ ����.Il IL-���.Il�1�
Tax 1VIap: ��� Parce • �Qc
Subdivision '
Phase/Section/ ot # l
Permit Valid for: Five Year:
Type of Facility: �`'�� �
Number of• Bedrooms � /
Proposed Wastewater System
Proposed Repair: i� 5
Improvement Permit
Non-expiring �
New � Addition
�Emploxees / Seats:
Permit Conditions: �� �I�% ,5�2�� �
Authorized State Agent:
(X) Owner or Legal Re
Water Supply: �`e t �
Projected Daily Flow: `3(v o gallons/day
Type:
Type:
Date: �� 3
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 applicanbproperty owner to insure that all Person County Planning and Zoning and Building Inspections requirements are met This
[mprovement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeat 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
and Rules for SewaFe 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 wi11
remain potable.
-
Aut6orization to Construct Wastewater System
See site plan and additional attachments (� j.
Proposed Wastewater System: 0-2� ^�S' ��(*)Type�i4 Design Flow 3� � gal./day
New � Repair _ Expansion _ Soil LTAR. �• 3 o gal./day/ftz
Type of Facility: � Basement: ,� Yes _ No
(*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Deparlment.
Wastewater System Requirements
Tank Sizz: Sep�ic Tar�lc �(9 � ga(. " Pump Tank � S� gal. Grease i rap � gal.
Drainfield: Total Area (i0 sq. ft. Total Length 3O� ft. Max. Trench Depth 3� in.
Trench Width � ft. Min.Soil Cover � in. Min.Trench Separation � ft.
Distribution: Distribution Box
Specifications: �7 lBd �
_ / Serial Distribution,
� ��� � � .��
_ / Pressure Manifold �
�s�l� s�i�llnw-er- �(�a��, _ 3�, <<
Authorized State Agent: � Issue Date: �C"-3 �t 5
Permit Expiration Date: Z 3— 2 d
Tlte system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the conditions
and specifications of this permit. �3 _�_� �
(X) Owner or Legal Representative: Date:
,
J �J
Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
pVC �aoe VaFve
PurmBso�
��`�. � IPI��.����
�E;��� �'— � �� � .��.0 � �� lQ�.�e�� � Si
� Owner:
Tax Map: �2 Parcel #: �.� 5_ Date: 2-3 —! 5
�.ane �'�p Tap (�c�a) Tap �'lo� Line Lengih &�io�v / ��ot
# i)iaYne�er(�) ( m) � � � (ft)
a 3/ �fo (2.5 av � Z.5
B 3� �{o � / Z, S u-0 � .125
3 3 `f� 2. 0-�' .l2
4
5
( �/Pr�.� a
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9
10
�� ft of line x 65 al. per 100 ft= 1 q 50 t�--`�' : 100 =�� 5 gal
75% x��" ga1= �t �n gal per dose � gal per minute (gpm) = k'low Itate
Friction �ead �
I,oss: ,+i� ft per 100 ft of supply line x N �R� ft of supply.line =100 =�' S ft
ff��_ ft x 1.2 =�� ft of friction head
� ( G'�� � � � �
d►s�nc�
�PP ►-n x.
Manifold Siae: �" Force IVlain Size: 3 " PVC
�otal Dynamic �$ead =�ft of Elevadon head + 2- ft of Pressure head t � � ft of
Friction Head = �_TDH �
Pump Requi�eanent: �� GPM @� 3 - ft of Head,,
Drawdown: � Y� gal per dose : i3 gal per inch =�_ inch drawdown per dose
30
�ea�allBesig�t �foranation .
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PUMPLINE TO DRAINFIELD 16A
SEE PLAT CABINET 16
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 BdOK 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
BUIIDING FOUNDATION.
CONSTRUCTION IN THE PROPOSEO
BUILDING AREAS MUST MEET ALL
PERSON COUN7Y SETBACK REQUIREMENTS.
� � 15�
I ` PUMPLINE
�� r EASEI�IENT
i ��
� 21A �
� 1 �
``� �
— — � 192 99
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PUMPLINE
EASEMENT
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; IVaaie ��' �� � Tax Map # 2 1� Pa�cel #[ Q 5
"'Si�ii. '. .. Sectioa/Lot#
-�� 3 — 5
Authoxized State � t Date
S,ystemconrp'one�s�pveaeneappmxitnmte�ronroursonly: Thecaniroclbrrnrusflagihe.ryste�nprio�to
beg,r�riing ths &�sWlahon to ir�rr�r� thaepmpergr+�ile rs mrrinwined
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15'
� PUMPLINE
17 A �'l EASEMENT
�
INSET DETAIL
DRAINFIELD
18A
SCALE 1"=60'
DRAINFIELD DATA
L-192 S82"43'S4"W 41.44'
L-199 S84°11'45"E 28.87'
L-200 S29'43'10"E 66.43'
L-201 S01°00'33"E 40.01'
L-202 S54'OS'25"W 44.35'
L-203 S86"11'42"W 52.00'
1-204 N07°09'08"W 125.82'
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VVELI. GONSTRIICTION RECO�iD
Tl�a farm caatc tmtd fors¢�It otmnSGple �re1Lt
L�Vdi nis�ctarLnSormatiaaa
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3. SVdI lisz (check wcU nscj:
Q��� [3i4dvaicipaEfPt�blie -
aGeoshamal (EIeatinS�liug SaPP1Y7 C�i&`idaitial WacrrSu�pip (singlo)
OTndusniaklCommatial aK+esida[tial WataSo�pJY W��)
DAqnifer �Y.ed�uE� f]Qm�udwatccltaaediation
��i�$ppt8geandl{a:avcrg OSaliatvSastier
[7AquiferFt�eS[ C75tonanvaOerAra+naSL
pF�rriaienmi"i'edinol4�r flSuluideneaCantmi
�Geosna�cisi Cctasca Loop} � - - - --- — '
336-598-9275 p.1
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FnriotermlU� OTILY:
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IE�ra.�n�r�san�a��rn.��.Il �3[��.11�:l�
WELL PERMIT
(New� Repair_)
Tax Map: �� Parcel: Q� ��
Subdivision: •P Lot:
Applicant's Name: ✓�d� Y�flS.sZ
Mailing Address:
Phone Numbers:
Location of Property: �l j) �t �-P� �`� �C S d-� �'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
Other Conditions/Comments:
Permit issued by:
�Tew Well:
EHS/Date
Location: 3 -
�' Grouting:
Well Log: /?fJ
Well Tag:
Pump Tag: �—
Air Vent: ✓
Hose Bib: �—
Casing Height: �
Concrete Slab: ✓
Date: `Zr 3 �l S
Certificate of Completion
OL,iner:
EHS/Date
Wetl Driller: ��,2,n���9'y��
Pump Installer: `�
Approved by: ' ►�.,
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
DAbandonment:
Date: _
Method/Nlaterials:
License #:
License #:
Date: �--'7- (
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
���,s�- ���.���
�,_ � � � ����
7E�e���-��,.-„-„ ��.��.Il 7I���.Il�I�
Tax Map: � Parce • �QS
Subdivision
Phase/Section/Lot # (
Permit Valid for: Five Years
Type of Facility: �j�
Number of: Bedrooms � / �
Proposed Wastewater System:
Proposed Repair: � 5
Improvement Permit
Non-expiring �
New � Addition
�Emplo�,ees / Seats:
Permit Conditions: �PP ��`�2 5����
----����
Authorized State Agent:
(X) Owner or Legal RE
Water Supply: �`e l �
Projected Daily Flow: 3(�ogalions/day
Type:
Type:
Date: ��- 3 �
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 l�iorth Carolina °Laws
a�:rl Rules for Sewage Treaiment and Disnosal Svstems'(15A NCAC 18A .1900). l�ieither 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: /-20� ^�'S `��(*)Type �i 4 Design Flow 3�� gal./day
New � Repair _ Expansion _ Soil LTAR. � 3 o gal./day/ft2
Type of Facility: 1� �S- Basement: � Yes _ No
(*) System Types Illb, Illbg, IV, and [; require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Siz�: Septic Tar�k d(� a gai. "' Pump Tank � S�� gal.
Drainfield: Total Area ii0 sq. ft. Total Length 3O� ft.
Trench Width � ft. Min.Soil Cover � in.
Grease i rap � gal.
Max. Trench Depth 3v in.
Min.Trench Separation � ft.
DistribuHon: Distribution Box / Serial Distribution . / Pressure Manifold �
Specifications: �7 l6d � �� vi2c� ; � ✓Ld� � �tS��� ,Sj'(4��n��
��t 4t,� 38 `�
Authorized State Agent: � Issue Date: '�G'-3 �! S
Permit Expiration Date: Z 3— Z �
The system permitted is: Conventional /Accepted _�/ Alternative / Innovative . I accept the conditions
and specifications of this permit. 3^�_) �
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
Application Date: � 5 T I � ,� c� .� j� ��ke Tax Map:
Amount Paid: 000 , Qv �a0�, �� � � � �a� � Parcel #:
Receipt#: 3 I QO �- c.12�k IS' i 6 �' G�/ o-�
1
❑
�i
�ile Home
$150.00 (
Permit Q
� '� �2 �3�0.
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IL:�ravr$a anan*•,*�,,.�aa�.�n.�. Ir�x� w.11�lia ���/j•^� ��•
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Application for Services (Septic Systerns and Wells)
Services Re uested
Permit (Site Evaluatiou) ❑ Coastruction Aut6orization
3300.00 (if> 600 d) (Fee is de endent on the type of
Replacement or Building Addition 0 Permit Revision
f site visit required) ��s_nn
❑ Repair of Existing SepEic System
Application: No Charge/ CA $150.00 or $300.00
1) Service��R ques�ed ��, . J J,..
Name: a��-' `J � �f •'• Phone # (home): �3�' �%�/'%� J���
Address: �S ��, Lr' (wor(c%ell): :�3 • � - �5�, �
r : n. . � A
- ,I1�,rV1U y? �(�DIAJ-��VIl� �
2)Name and address of current owner (if different than applicant): ifl/V i����
Name: �'S G �� .
Address: •
3) Property Description:
Address and/or directions to
Lot Size: Subdivision:
�
r.ot #: �� 3 l
4) Proposed Use and Type of Structure:
Residential 1� Business/Type: Other
Number of bedrooms � / Number of people served (seats/employees):
Basement: Yes %� No (with plumbing: Yes No ____)
Gazbage disposal: Yes No ��
5) Water SupplY:
Private Well � (Proposed i` Existing _)
Community Well: P.ublic Water System:
Are there wells on the adjoining properties? No Yes '�C (please show location on site plan)
11�ote: A comnleted annlication must also include:
➢ A pladsite plan of the property that shows properly dimensio�s and the size and locatiort of all
proposed structures. �
➢ A sighed copy of the `Lot PreparatioH' form ver�i�g 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 t6e site is subsequently altered, or if the intended use changes, alt
permits �nd approvals shail 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)