A24 196Application Date: � 5 � / � ,� � ,� � � � �ke Tax Map:
Amount Paid: 000, L1U �aDO, �� � � i �A1 � Parcel #:
Receipt#: 3 ' � � � _ �.�k 15' � 6 � �l �
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Application for Services (Septic Systerns and Wells)
Services Re uested
Improvement Permit (Site Evaluation) ❑ Construction Aut6orization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the type of system ermitted)
❑ Mo6ile Home Replaceroent or Building Addition 0 Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) 0 Repair of Existing Septic System
$300.00/$200.00/$75.00 Application: No Charge/ CA $150.00 or $300.00
1) Servica}�gques�d � J f
Name: �i�� O�'f•'• Phone #(home): �3'� ���/'% J��,.S�
Address: jS ��, L�c� (work/cell); :�� � � - ✓'S�'i�
' �'?�
r , �,. ,
,�10�� ���r�D�►l�.wf �`
2) Name and address of current owner (if different than applicant); �
Name: �'S' G �.� .
Address: •
�
3) Property Description: Lot Size: Subdivision: Lot #: �� �
Address and/or directions to Property: ,_
.
� r . �,' �►
J
4) Proposed Use and Type of Structure:
Residential � 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 Suppl�:
Private Well � (Proposed i` Existing _)
Community Well: P.ublic Water System:
Are there wells on the adjoining properties7 No Yes •� (please show location on site plan)
11�ote: A comnleted anolication must also include:
➢ A pladsite plan of the property that shows property dimensions and the size and location of all
proposed siructures �
➢ 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 iatended use changes, all
permits and approvals shall become invalid.
Signature (Owner/Legal Representative): <— �J` � Date : I ' ,�7 � ��
10/08 Person County Environmental Hea(th, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
_��, s� ���.� ��
` � � � ����
?E�e�-��-��.�����.Il IF� � �.11�l�
Applicant; � a �2
Permit Valid for: Five Years
Type of Facility: �
Number of: Bedrooms � / C
Proposed Wastewater System: �
Proposed Repair: S �,,/
�
Improvement Permit
Non-expiring �
New � Addition
� % Employees / Seats:
PermitConditions: �� Sr � -S��LI
Tag Map: � Parc 1•%�
Subdivision �PS2►�
Phase/Section/Lot #
V�'ater Supply: �e�(
Projected Daily Flow: G n gatlons/day
Type: �
Type: �
Authorized State Agent: ,�Q'ri, �c Q �'''�'� _ Date: `E �3 �[
(X) Owncr or Legal Rep esentative: Date:
The issuan�e 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 Gounty Planning and Zoning and Building Inspections requirements aze met. This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The lmprovemeni is noi affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws
ruld Rules for Se►�ag� Treaiment and Dunosal Svstems'(15A i�1CAC l8A .19U0). Neither Person County nor the Environmental
Health Specialist warrants that :he segtic sy�stem will cantinue to fanciion satisfactorily in t6e futare, or ihat tbe water supply wi�l
remair potable. _ _ _ _
Authorization to Construct Wastcwater �ystem
See site plan and additional attachn:ents �_).
�
Proposed Wastewater System: PP�� W1 / k�.P
New � �Repair _ Expansion _ �
Type of Facilir,�: 3� � �5 -
(*)Typ�Ju- �l � Design Flow 3� � gal./day
Soil LTtiR: . `3 � gal./day/ft2
Basement: � Yes _ No
(*) System 7'ypes III6, Illbg, IY, and V, require periodic system inspections by ihe Person County Health Department.
��e .� �.
Wastewater System Requirements
Tank Size: Septic Tank l � d0 gal. Pump Tank s o � gal. Grease Trap `� gal.
Urainfield: Total Area `��� sq. ft. 'fotal Length 2 C9 � ft. Max. Trench Depth 33( in.
Trench Width 3 ft. Miti.Soil Cuver � in. Min.Trench Separation � ft.
/ Serial Distribution
�uthorizzd State Agent:
T'he system permitted is: Convention�
and specifications of this permit.
{X) Owner or Legal Representative:
� /Accepted
/ Pressure Manifold i�
Issue Date: 2— 3—( S
Permit Expiration Date: 2-3 —ZF�
. I accept the conditions
Date:
Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
PUMPLINE TO DRAINFIELD 16A
SEE PLAT CABINET 16
PAGE 491-496
FOR PUMPLINE DATA.
3"PUMPLINE INS7A�LED FROM LOT
TO OFFSITE ORAINFIELD AN�
PREVIOUSLY INSPECTED BY THE
PERSON COUNTY ENVIRONMENTAL
HEALTH DEPARTMENT.
REFERENCE IS MADE TO THE
RESTRICTIVE COVENANTS RECORDED
AT DEEp B00K 856 PAGE 428.
3" PVC CONNECTIONS SHOWN ON
THE LOT AND DRAINFIELD ARE
APPROXIMATE LOCATION ONLY.
WELLS MUST BE 50' MINIMUM SETBACK
FROM ANY DRAINFIEID AREA OR SEPTIC
PUMPLINE EASEMENT.
WELLS MUST BE 10' MINIMUM SETBACK
FROM PROPERTY LINES AND 25'
MINIMUM SETBACK FROM THE
BUI�DING FOUNDATION.
CONSTRUCTION IN THE PROPOSED
BUILDING AREAS MUS7 MEET ALL
PERSON COUNTY SETBACK REQUIREMENTS.
20A
16A
21A
I�� ___�..
— �Z�
r 195 � PUMPLINE
I EASEMENT
� 3° PVC
CONNECTION
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26A
� 17A
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---- 2�9 _----
_ _ 15' PUMPLINE EASEMENT _ _ _
"PINESBOROUGH ESTATE"
INSET DETAIL
DRAINFIELD
19A
SCALE 1"=60'
DRAINFIELD DATA
LINE BEARING DIST
L-193 S82°43'S3"W 17.93'
L-195 N86°12'24"E 27.64'
L-196 NO3°36'09"E 56.59'
L-204 N07°09'08"W 125.82'
L-208 NO3°32't9"W 131.45'
L-209 N88°37'40"W 42.36'
L-210 N01°55'25"E 56.84'
L-211 N04"54'S6"W 45.15'
L-212 N28°22'00"W 29.30'
L-213 N12°12'23"W 68.42'
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1'iuthorized State :t�geat Date
System cviinp'mfeets �jiveaent a,ppmximate�conioars only.' The canfnrcJbr mrut flag the system prior to
begrnni�g the ars�talla�ton to ieisr�ne ihdapropergrade is �wintaired
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aL a�. �'�1C�
WELL PERMIT
(New � Repair � )
T� MaP� �� Parcel• l �
Subdivision: ,�o
Lot: �_
Applicant's Name: ��j
Mailing Address:
Phone Numbers:
Location of Property: S�jj c��- p� �� �S� .�
Permit Conditions:
1.) See attached site plrm 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 gucrrantee a potable water supply
Other Conditions/Comments:
Permit issued by:
�ew We11:
� � EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
AdditionaC Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Date: � 3 'Y �'j
Certifcate of Completion
OLiner:
EHS/Date
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
31/26/13
1
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IE;�� ��,.,,,�,��¢�.1t 1Hl[�.�,ll,e]� Owner: �'e �.�,�`�"'�
Tax Map: � Parcel #: ���P Date: 2—� ` I�►
I.ime Tap Tap (Scfla) Tap �lopv Line I,�ngth &'�oe�v I f�ot
# i)aarneter(�) { m) �:. (ft)
1 3/ �� , o , zo
2 3/c � /�, �� � 2 0
3 3 N �U lo • �, � . z�
4 3 D. ' . Zo
5
6
7 2- r► �4- -�-
�
9
10
� A ft of line x 65 gal. per 100 ft =� �: 100 =�� Q gal
7 5% x�� � ga1= /5° ga1 per dose � gal per minute ( g pm) _�'low Rate
�'riction �ead ^, � '� �N �'hP � k�
I,oss: + 5� ft per 100 ft of supply line x �°o ft of supply. line = 100 = �� ft
_[� ft x 1.2 =/�' _ ft of friction head d iS�u c-2
Q�Pti°��
Manifolcl Siae: �_" �'orce Main �ize: 3 " PVC
�otal Dynamic �$ead = S fl ft of Elevadon head + 2 ft of Pressure head +�ft of
Friction Head = �_TDH
Pump i�eq�ai�ement: 4'3 GPM @ �D� . ft of Head ��-���' �
Drawdown: �fl_gal per dose :�1 gal per inch = S" inch drawdown per dose a��OX •
'30
�es ai D� Iiaforpnation
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9mmmx I � S �
4Yanifoid Sizr ! � Ta s
�i%ld Max No. Taps off oue side
�ize (atednce b�s :or ta in �oth si
'i4» ta s 3/a" taps 1" ts
2" 4 =
3� 9 5 3
du �6 9 _
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' �`%w �r iap
Size illt�erial Ffa:c G�Yl
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�," Scned 10 i•1
;r, °� �c1:ed 80 1 � 1
j, .. �ciied 40 1:•=
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�aavra��aa�� ¢3aa�.�.� �����.��a.
NEMA 4X Simplex Control Panel
h" X �4" Pressnre Treated
_ Sloped To Sbed Water 12° Separation
\ Elect�cal Cox�lnit �
b" Cover •
i.,
Inlet Fxnm Septic Tas1k
+1" SC$ �40 PVC Pipe
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• `AccessCover• •• ' ' e~ ' ,ti ;
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I • � t 7 ��� • . • •�• • '� , i
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r,. Opening Filled With � . Anti Siphon Hole' \
Po:tland Cesnent Gmut �� H��
Cl�eck
• Valve
Higkt Water Ala:m Level
, (6" Separatien�
H�ghLevel- Pump Ox -�._.��
;, ;: � « rVapozLock
Hole �
. .� �Drawdrnm �IIp H�1)
•Law Level -Puxnp Ofi ----�'
r'• .
�••S
• ' Pxecast Coz�crete Tank
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T�x M�� ' � F�i�cEl #
S�ihcllivision � �� '
Plr.��s•e Sect�ion"Lot # �
Au� Seal Both
Ends Of The Conduit
-'- 24" Maumum
,. ., • ,
Threaded Gate Valve •
Union ! � r-�
Zip Co
Tizs
Concrete Riser
6" Separaticx
' • ,' %r:.d•%�•-�.�
4,,:.�.-..-Portland Concrete G:out
� �� �'Airt7C • ' � .
� Opening Filled Witk
Supply ' ' po�� Cement Graut
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4utlet To Distttbuti�on
2" SCH40PVC Pipe
R°pe Float Wires � �
4" Concxete
'SI� $lock
': . :� • '. - ''`
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Flaats , �;
�.Removable '.:'
F7oat Txce ��
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PUMP ttA_ � �
Pump ust ge Rated ?o Deliver
� � 3 Gallons Per Hinute .
AgaiRst �(p_Feet OE Tota.l
Dynaeaie Head (IDN) .