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�/ � � �
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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)
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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)
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��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 =
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6" Cover •� ' � � Access Cover• � •• , ' ' � ~ ' .f �
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.'' � '� � t : ; ..`: . ;, . � .
; . • • - - . •�
. i.• P rtland C�mdent 1tGraat . Aziti Sipluon Hole' `
Irlet Fmm Septic Tank �� g��
4" SCH 40 PVC Pipe � �
� Check
• Vaive -
' , $igh Water Alarrn Level
(6" Separation)
High Level - Pump Ox ,��
� ;, ;� � �� rVaparLock
: ),�L Hole r.
• .� .��� Draxdavin �Up H�1)
,�
• •Law Level-Pump Off ----r�
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� •• S
P:ecast Concrete Tank
� � .•; (MatebalStrength>35L
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T�x M��� % P�rcel # �
Suhelivision ' � • � "
Ph�as•e Sc�ction Lot # '
Duct Seal Both
Exids Of The Conduit
r' 24" Mi�+ixmm —i
'' '' '' ---- -
Threaded Gate Valve
— -. r
Zip Coxd
Ti�s �
4 ° Conciete
�SIj Block
' : . : � • '. - ' �` .
Concre{e Riser
b" Sepaxaticn
• • ,' � %�:.v;1' .
4�:.r�-Portl.and Coxicrete Gxout
.. • Mastu - - : .
� � Opening Fiiled With
Supply � : portland Cement Grout
� ..
Outlet To Distnbutiox
2" SCH40PVC Pipe
Float Wires �
• f
i
F7natt ,
�.,Ftemovable • • •
Float Tree �.
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r� . �
. ��5, -.:, ''
� 1 Se� ��,r�a�v� T�rix
� c�r_ � �
Pnmp Hust Be Rated To Deliner
� 3 Calloas Per Hinate,
Against �03 Feet QE Tota.l
Dpaataic pead (IDH) .
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1��-�� ��¢�.0 �[�.�.�.,�� Owner:
Tax Map: Z Parcel #: � Date: �ll�"�t 5
I,ene Tap Tap (Scfl�) TaQ �lop� Line �engih �ovv /��ot
# I)iameter(in) ( m) �:� (ft)
1 3/ id ?• 5 8c7' !cn
2 3l 4� � IZ.S � .
3 3 O 10� f . Zo
4
5
6
7
8
9
l.0
N� ft of line x 65 gal. per 100 ft=�� � g : 100 =�( gal �
�3% x 2�° ga1= ! n S gal per dose �_ gal per minute (gpm) _�+'low Itate
S� �j ����
Friction �ead � I U �P
i
Loss: •`f 0 ft per 100 ft of supply line x'�' 2i n� ft of supply. line ; 100 = 9 ft ��Q k�r{' � aDP ry i�'
�_ ft x 1.2 = i I ft of friction head �
Manifold Siae: �" Force Main �ize: 3 " PVC
�otaI Dynamic �$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
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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
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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'
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