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A24 197Application Date: � 5 �/ � ,� c� _� j� i���Ce Tax Map: Amount Paid: OOd , OU �a00. �� 6 � � �a ` � Parcel #: Receipt#: 3 I 60 �- c.�°.�k I� � p�/ � � � 6� �� �� � � � �2�1 ��� ' f �„ ,,, .. .�! ���� � ��t'S�� �"�'1� �� � ''__"� C� ����� ���2 �.A'. IL;�.d-aa .�naa.����:.�,.11 'IL�T� �.Il�7� � d' � Application for Services (Septic Systerns and Wells) 1) Servic ques ed -�--- Name����� �o'�f' J f'. Phone # (home): �3�' �%�/'%��%��� Address: �j S � , Lr (work/cell): :�3 •���- �,.�� � l" � �' M { �i � J�I � �►D�I� ���so�i�.� � 2)Name and address of current owner (if different than applicant)c � Name• 'S' � �r� - � Address: � 3) Property Description: Lot Size: Subdivision: Address and/or directions to Proaertv: ., �, 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 Lot #: �� 3 l . 5) Water Supp1Y: Private Well � (Proposed i` Existing _) Community VVell: P.ublic Water System: Are there wells on the adjoining properties? No Yes '?C (please show location on site plan) ! Note: A comnleted annlication must also include: ' ➢ A pladsite plan of the property that shows property dimensiohs and the size and location of all ' proposed structures � � ➢ A signed copy of the `Lot Preparation' form ver�ing that the properly 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' .�7 � �� 10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) ���, sf ���..� �� `^ � � � ���� 7E�°s��u-��� ����.11 IL—���.Il�I� �] Tax Map: G�� Pa el: �f I� Subdivision � vu� � Phase/Section/Lot # 2 O Permit Valid for: Fiv--� Type of Facility: � � Number of• Bedrooms � / Proposed Wastewater System: Proposed Repair: �Q � Improvement Permit Non-expiring � New � Addition �Em,�loyees / Seats: Permit Conditions: ��� �t�� ���� Water Supply: �`ef( Projected Daiiy Flow: 3�o gallons/day Type: c�i � Type� � Authorized State Agent: ✓� � a��� Date:- —�l =( (X) Owner or Legal Re resentaHve: 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 c6anges. 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�:d Ru[es for Sewa�e Treatment and Disnosal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warraats 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: � PS w/ ����+P (*)Type���'� Design Flow 3�2 � gal./day New� Repair _ Expansion _ Soil LTAR: � 2� gal./day/ftz Type of Facility: ��Q f��S . Basement: � Yes _ No (*) System Types Illb, Illbg, Iv, and i; require pe�iodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Sizz: Septic Tar�k � 0 v� ga;, � Drainfield: Total Area �3 o sq. ft. Trench Width � ft. Distribution: Distribution Box / Serial Di Specifications: 3 Pump Tank �s 4� gal. Total Length 2( � ft. Min.Soil Cover � in. :�{bution . / Pressure d�� Nia+-'F Stt Grease i rap '— gal. Max. Trench Depth 3(�o in. Min.Trench Separation � ft. �ld K ; 5�� D�r,-,,►A� /u��� �C' Authorized State Agent: Issue Date: 2r «'� S Permit Expiration Date: 2— (�"Z o �1� ���, �P The system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions and specifications of this permit. —, (X) Owner or Legal Representative: Date: � Person County Environmental Health, 2S S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �.�,�.s� ���.� �� ~ `�'^ � � � � � Jl ��aw-a�c-o�a.,•�,•-,• ¢�na�.ra.�. �]�ae�m.���a NEMA 4X Simplex Contml Panel 4" X 4" Pressnre Treated Sloped To Shed Water 12° Separation � Electrical Cox�uit = � , � . 6" Cover •� ' � � Access Cover• � •• , ' ' � ~ ' .f � � • _ - ' ;, . —� .'' � '� � t : ; ..`: . ;, . � . ; . • • - - . •� . i.• P rtland C�mdent 1tGraat . Aziti Sipluon Hole' ` Irlet Fmm Septic Tank �� g�� 4" SCH 40 PVC Pipe � � � Check • Vaive - ' , $igh Water Alarrn Level (6" Separation) High Level - Pump Ox ,�� � ;, ;� � �� rVaparLock : ),�L Hole r. • .� .��� Draxdavin �Up H�1) ,� • •Law Level-Pump Off ----r� ' � �' . � •• S P:ecast Concrete Tank � � .•; (MatebalStrength>35L �� • • , � •�,; . . . ' • . T�x M��� % P�rcel # � Suhelivision ' � • � " Ph�as•e Sc�ction Lot # ' Duct Seal Both Exids Of The Conduit r' 24" Mi�+ixmm —i '' '' '' ---- - Threaded Gate Valve — -. r Zip Coxd Ti�s � 4 ° Conciete �SIj Block ' : . : � • '. - ' �` . Concre{e Riser b" Sepaxaticn • • ,' � %�:.v;1' . 4�:.r�-Portl.and Coxicrete Gxout .. • Mastu - - : . � � Opening Fiiled With Supply � : portland Cement Grout � .. Outlet To Distnbutiox 2" SCH40PVC Pipe Float Wires � • f i F7natt , �.,Ftemovable • • • Float Tree �. � r� . � . ��5, -.:, '' � 1 Se� ��,r�a�v� T�rix � c�r_ � � Pnmp Hust Be Rated To Deliner � 3 Calloas Per Hinate, Against �03 Feet QE Tota.l Dpaataic pead (IDH) . �ncr�v� ��� ���, � IPI��.� ��� --- � � �T�'��Y �'y� E��es�'� c�� 1��-�� ��¢�.0 �[�.�.�.,�� Owner: Tax Map: Z Parcel #: � Date: �ll�"�t 5 I,ene Tap Tap (Scfl�) TaQ �lop� Line �engih �ovv /��ot # I)iameter(in) ( m) �:� (ft) 1 3/ id ?• 5 8c7' !cn 2 3l 4� � IZ.S � . 3 3 O 10� f . Zo 4 5 6 7 8 9 l.0 N� ft of line x 65 gal. per 100 ft=�� � g : 100 =�( gal � �3% x 2�° ga1= ! n S gal per dose �_ gal per minute (gpm) _�+'low Itate S� �j ���� Friction �ead � I U �P i Loss: •`f 0 ft per 100 ft of supply line x'�' 2i n� ft of supply. line ; 100 = 9 ft ��Q k�r{' � aDP ry i�' �_ ft x 1.2 = i I ft of friction head � Manifold Siae: �" Force Main �ize: 3 " PVC �otaI Dynamic �$eaci = S� ft of Elevadon head + 2- ft of Pressure head +�/ ft of Friction Head = � 3 TDH � � �� � Pump Reqiai�ement: � GPM @ �D 3- ft of Head (� ��1 k � 1� Drawdown: /0 5�al per dose =�1"gal per inch = S" inch drawdown per dose +�o �ea�i I9esiga �for�ation ��... ;, sa�.w rvcT� �wn �r�, _. . r�w . � x�nrTv�.w ' ♦ � � [YOC9IIt/aLa] l�mt'amdv. . ]owl/me�oa -� y�«,� '� s . � — � - �. � : � � ,. , �[(�)1���0� iiii��iiiiiiii�ii+iiiiiiiiaiii� �������� �����N����������i'����r a ti• d" 5" l�Panifoid Siz.: J � Tap3 Max �To. Tags off one side r:teauce bv �z :or ta�fain� �oth ; 21 I �2 . . _ , ' Fiow er Tap Si�e �ldnierial Flo:v G?Yt �� " ScJied 80 �•� �, �° Sci:ed 10 %.� ; �• �cl:ed 80 !O,1 ,, ,. Sciteri ?0 1= ' :� PUMPLINE TO ORAINFIELD 16A SEE PLAT CABINET 16 PAGE 491-496 FOR PUMPLINE DATA. 3"PUMPLINE INSTALLED FROM lOT TO OFFSITE DRAINFIELD AND FREVIOUSLY INSPECTED BY THE PERSON COUNTY ENVIRONMENTAL HEA�TH DEPARTMENT. REFERENCE IS MADE TO THE RESTRICTIVE COVENANTS RECORDED AT DEEp B00K 856 PAGE 428. 3" PVC CONNECTIONS SHOWN ON THE LOT AND DRAINFIEID 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 I�EET ALL PERSON COUNTY SETBACK REQUIREMENTS. _ _ 15' PUMPLINE EASEMENT � L CE , � � ► � 2 2 A I � � ��� 21 A � / 187 MQLII �i�� 3" PVC CONNECT I ON. I� 186 18S � ��j � � ` 12' i � PUMPLINE I � 12' EASEMENT n � 3.,I� PUMPLINE r, � fASEMENT 14A � I � ° I i_a, r_ 19 A � v � � 16 A 1� tu'e 1=� r _. 1�I�',�2 = � r . �(�3_5a` INSET DETAIL DRAINFIELD 20A SCALE 1" =60' DRAINFIELD DATA LINE BEARING DIST L-177 S00' 56' 40" W! 07. 10' L-185 N73' 37' 34" W 40. 77' L-186 N25' 12' 30" W 15. 91' L-187 S89' S3' 18" W 29. 47' L-194 N00' 29' 39" E 19. 41' L-195 N86' 12' 24" E 27: 64' L-196 NO3' 36' 09" E 56. 59' L-197 N77' 28' 31" E 25. 50' L-198 S84' 36' 45" E 21. 03' � .. .��7�)� ������ • _ ::.. '�:�'���� 7L:aas?au�a�;^ �.o��m.11. ]E3GamA�s . � ,..��I�'E:,,�SHETCH � , IVaine, �vv t� � � . . Taz Map #�P�cel # � ,•.,.,::� .. � ' �Siib o � �. - Seation/Lot# 7 0 _' 2-1�-/S Authoxi2ed S ,Agcnt Date System c6hrp'oneais mjivesentappmximate�co��ar�rs only.' 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