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SlopedTo Shed Water
6" Cowx •
1
�.
Inlet Fmm Septic Taztk
4" SCH 40 PVC Pipe
NEMA 4X Simplex Contml Panel
4" X 4" Pmssure Treated Post
12" Separation
E�CtYLC21 COYI�l11t �
f ��
T�x M�� P�rcQl # �
Suhclivisioti � `'- �
Fh��se SQct�ioii`Lot #
�� Duct Seal Both
i
d I Ends Of The Coz�duit
24 u ZVllll]ItA3Itl
f. .� . ' . .. � �
Tiueaded Gate Valve •
• � Accets Cover• •• , ' : ; � 1 ?
• � - � r . J
� � � � 's . . • � ` ` • '� • .
�., Opening Filled With Anti Siphon Hole' `
Poziland Cexnent Graat (Drnvn Hill)
Cl�eck
Zip Cv
Ties
, Valve .0
High Water Alarm Level
� (b" Separatipn�
Higlt Level- F'uinp Ox
;. �% �y �( rVaporLock i ��
• �[ Hole a �
, ��.
• .': Drsxdo4m �Up Hill) �
. Law Level-Pump Ofi �
� . ��
�• 5
Psecast Concrete Tanlc � 4" Coivcsete
;.; (Material Strength >3500 PSI) $lock
`:•�.•�•� ; ; •� '-_� '.: ;' , � . . '�
Concreie Riser
' `� 6" Sepaxaticn
• '•� ' . � %r.�c/L!'•-~�`
',�.�..-Poxtland Concrete Gxrnit
Mutu • - '
� Opening Filled With
Supply ' ' poxtland Cement Crrout
Lina ••
Outlet To D'utnbutiox
2" SCH40PVC Pipe
e Float Wixe� �� �
• .r
i
Floats , ,
�ltemovable "• •'
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. � ` - . ,'�'
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Tax Map: Z Pazcel #: Date: �Z �— �
I.ene Tap Tap (Scfl�) Tap �'lo� Line �.eaagtig �ovv /��ot
# i�iameter(in) ( m) �:. (ft)
1 3'' � �7-5 Dd' <<zS
2 ' �{o �� J?• 00� . !2
3
4
5
6
7 Z
8
9
10 �
ft of line x 65 gai. per 100 ft= ; 100 = gal
75°!o x ga1= gal per dose � gal per minute (gpm) = I+'low i�ate �U ✓��P '� ��
I+'riction �ead � � I�v`"�� a`-1 x•
I.oss: •_�ft per 100 ft of s�ply line x'�ZSDO ft of supply.line = 100 = 5 ft
S ft x 1.2 =�_ ft of friction head , q,n�yo�
,� � �-e ". l wv
Manifold �iae: 3 "�orce Main Size: � " PVC
�otal Dynamic �$ead = S� ft of Elevation head + Z ft of Pressure head +�O ft of
Fricrion Head = ��TDH
Pump Iiequi�ement: �� GPM @ 5� ft of Head
i)rawdown: ZS al per dose :�3'gal per inch =�`� inch drawdown per dose
25
G,�essllDesigat �forpnation
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1luthoxized State Ageat Date
System cdrirp'oneats s�ji�e,reneapp�narimate�roniou�s only.' The eonixr�Jbr mrut,Jlagthe rysremprior io
begiruring fhe ms�irllailan to iqs!+ne thaepnopergrade rs nwintwired
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,� PUMPLINE
�ry 2 2 A �N . � _ � � .�— EASEMENT
N _ � .
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Tax Map: ?i Parcel: �� g
Subdivision
Phase/Section/Lot # 2 (
Permit Valid for: Fiv
Type of Facility: 3�
Number of: Bedrooms
Proposed Wastewater
Proposed Repair: �
Improvement Permit
Years i� Non-expiring
2 New � Addition _
3 / Occunants / Emnlovees / Seats:
Permit Conditions: S�' C�`-�P Sr-e'�c �,
Water Supply: W P��
Projected Daily Flow: 3 v allons/day
Type: ��
Type: ��
Authorized State Agent: ,��r� �,� Uu�%I�C� Date: �
(X) Owner or Legal ReprPspntat»p._�� , , �., _ _ Date: �0
�
u
The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibi(ity of
tl�e applicanUproperly 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 Piorth Carolina `Laws
mrd Ru[es !or Sewape Treatment and Disposal 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: � ���1✓Y1 (*)Type„L.IL•�/ � Design Flow 3�� gal./day
New � Repair _ Expansion Soil LTAR: , 30 gal./day/ft2
Type of Facility: ��1e %�• Basement: � Yes _No
(*) System Types IIIb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank [� � � gal.
Drainfield: Total Area � � 0 sq. ft.
Trench Width � ft.
Distribution: Distribution Box / Serial
Specifications:
Pump Tank � S4O gal. Grease Trap � gal. '
n �> •/
r
Total Length Z� � ft. Max. Trench Depth 3� in. �1—�
Min.Soil Cover � in. Min.Trench Separation � ft.
�- �ay; �r�
/ Pressure Manifold �
� . . _ r
w�
5
Authorized State Agent: � v� Issue Date: '`�'Z(o —�`f
�iD �f ^ � Permit Expiration Date: —Z —
� [ •��
The system permitted is: Conventional �/Acc ted / I rnative / Innovative . I accept t e con '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)
Barnette Well Drilling
Z1�a form can bc nscd For s¢�gle or m�iltipk we(Is
L Wdl Contraetor Ln(orma6oa:
il'r �,
Wdl Co�rrac[or Name
� �.7 �---A
NC Well Comrncto: Ccrtir�cauon Kvmber
Bare�ette Weli Drillin
�Coa�any Naace
2. Wcil Cons[rncbon Pern+itii: ��
Urt oll appYrcnb4 well coQauvcrlonnerntiu (t.e Crrevy. Swt
3. Wd1 U'se (check we[1 usek
Wa W Supply y�'eEl:
aAgrialWral ❑.��Mv�nici
�GcWhcrmal (Hdting�CoolinS �PP�Y) NfiesidG
�IndustriaVCommaciat DRcsidei
�Gziaaliun
Noo-�4 atcr Su pply �V cf I:
aMonitonn8 OtLtcove
lnjettioo SV�JL•
❑kquifcr Rcd�ar8� ❑Gmund
nayuirer scoragc aa! Recovm� asalirriry
O Aquifcr T�st ps�� µ
�FxperimcxrtalTcchnology �S�s;de
QGebthcrr.�al (Ctnsed LooP) G'Craca
3365989275 p.1
G�l�`�-T � .
For is�trroal Uu ONLY:
i4: wwTER zorrFs .
� FROM Tp pLSCR[p7'1pN
�ti f� J� f� T � /
in', ft �.,, ft � � .� )
� lq�
Yar:nnee. etc j
�VPubiic•
ala'alcr 3uPPtY ��ao s)
al Watet Supply (shatr.il)
s Remetiiation
rier
Urainage
Controt
iui unQer M2l Itn
k � r�
1+1ER��AS7IVG.Oit.^
TO
tc [t.
fi f�.
REEN�:'�. � �
TO
IL 2
Q (t
m G�R
�t Cc
[� ft
cort�+vs�, rAc
70
it rc
ft f4
l:I.iNG'f;OG� � aic
ro .
tt �C ft
-�, �� �So �e z � � !'uc.
G�. � eotbetmul:clased�lbo� ?
MCCFR 'f1tICIQYE53 �.. MATERIAL
ia ,
ia
TER sLOTSIZE 77ii IIS TiAI'EF
M
ia
d.DataR'cil{s)Completed: 3/� �rW�I71AiE l� ��`�� L� -r5 ft *t � cJA� Sd�/ - C./�
�- .�D « 821:f
Sa Wc0 Locstion: �a� �o s � . 5a {k '� � .� � •
�I� � 1Q � j' F+� v� .L t'�-f Z � r�. �.
FaciGry/�wm 21urie FatiliRy Iilt� (if=pplica6Ic) � � .
% I�Y✓e!!Q (�.0 LC� r'1 C�.s7'�'.�1f��1 f� � 1���' !t ft
P.hpsiul AddxssS C'�eY. and— 7a�p � . . . , , . . . .,., . . .
.,�2i•REiHA&KS ..�,�:• � � ,�..-:< .. . -� .: .. : ..: .... . . . � .... � �:
��P 5�� / 9�
�r � ��;s�ox�. rrm,
Sb. iatilndc and LanQ [ndt in degrees/minutrslucoed�or decima[ degrces: ���r.��o�: •
�tiMCd �� OnC �8in0t�8 15 61Iff1tlW[� �
_ 1'� - 3c --.35 N �' � " OI3-.� ! � l�r� z� �. ��e�SL 3`� �S
Si�ceafCutiSod WcJ! Cuntracfar Daca
4. Ts (are� ttr� tv.e1l(s): �Ycrtuaacnt or OTm�pol aro
Sy srgning �l+trjorar, f herelry cr�r�/y nc�u (he wett(S� MOY �MIt� dn�l/vUtGlk aGCOflIGf1C:G
with !3A'!�ilCdYC.OlO� or l.7A NCAC Q�G .02Q0 iFdl ConslivctJonStmrdards miid tlm�.a �
7_7st6ts.artpairtotncxis�ngz►e�l: OYes or t7Pio"� copye�I�fsrrcvndhn.s6eenprwWdedeouuwe[loxxur.
IJd+is Ls a repalr, fJ! ara kne�vn ..+c1/ can.ur�.crion lr�armctPan _mrda�lotn nc� �ramrY�oJtb.e .
+r1Mir rrnder �1 J^�rmrk� sr��on or ou+hs.6ec,� ofddrJ6rm. 23. S�ibc' d"u&Yaot or adtlitiou;IweB dcta�75:
/ You R1ary'use tHe badc of $tis pa�,o'W proride additiooal weil siie daa�7s ar wdl
B.Nam6crotweAs�vnstnected: / tdnstruet7onddails. Youinayafsaatiachadditidnal-pagesifnccassary.
Fore�ultlpFebrJectioeorxwe-svetersu/mlyx�rllsONLYwHhdr samttwnslrrtctPes.youcm� '
ec
:ubnHr one form. 5USI12IITAI. IN57'UCT'1 OIVS
9. Toia� wEJi d�pt4 belowlaud:urfaee: �" 6� (�,t� 24a For AlI Weft� 5uhmir this -Soaa vn`t6in 30 days of. canpTdian of well
Forrm.kiple�.rtlsliitofJdepJ,s{fd�rent(u�li-3Q2W'a�d1�1oP') ednstiudiorttiotfi�foliowii�
I@. StaBe water level bclo�r fop etea'siog: �� {fY.) �+�+� a[Wx[er QaaGty, Information 1'rooesaing Uait�
IfMtttrleur! !s a8ovctnsi.tr„ ae "+' 1617 MaSI 5eryiee Cu[tu. Raki�h� I�TC 2769�-! 617
I.1. Borehole diamc[er_ � [a.) 24h� Fnr Ihicetion VVells: In yddition to sc7eding the form W the address in 24a
�y� .L above, aLso subtai[ at eoFty of th'is form wiEhin 30 days of compktion oF wcll
12. 1�`dl eooatruction method: /'�'/Y�c. DC �i /��R- i9 eanshudionia the following.
(ie. a�er. �oca7. cal� d;nct puil�, ctc.} I .
DivisiodoCWater Qaality. Undeegraand Injcefi� Conxrd Prognw,
FOR WATER SIJPPGY WELfS ONLY: I lfii6 Msi1 Suvice Ceoter, Rateiah, NC 2'T549-t53G
I3a. Yie[d (g�sm)._ � Methad nCtes� ���0 RfiflUt 24e. �'ar Nster Siioolv 8c Iniection R'd�s: ln sddition to sCndingthe form to
HTH � �t addiess(cs) a6ave, also 5ubaiit one eogy of tliis foein within 30 days af
136. Disinfcctioa typc; ��Q '� %2 rillp �p2etian of wd! constructioa to Uio couniy hcatti� drpartmen� oC the cuunty
whcre consvi�aed.
Foem (�W-1 North CarqlLea Depukwent�afFaev"uonroent sad Nalmal Resrnsecs - Qivisien olWwtrs Qiieliry ReviudJau. 2613
���,s f ���.� ��
- � � � ����
���n��������.� ���.��.�
WELL PERMIT
(New x Repair _ J
Tax Map: �� Parcel: � i g
Subdivision. �_�pSQvv� Lot: z �
Applicant's Name: ��OSQ
Mailing Address:
Phone Numbers:
Location of Property:
� `� /' i ✓l'�$�1dv'v
% S �,�es !Q�' --'�
S � S/� .� �
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 wa r s pply �
Other Conditions/Coraments: 1�f'PA W'e�i d'�'f' �� �� �.�a� ar'2� S�������5� �C�
Permit issued by:
�1ew Well:
HS/Date
Location: 3'1-9-� 5
� Grouting: `CQ—1 S
,W` `l �.`e�� ^ Well Log: 5 3-�-l5
� Well Tag: �-�t-�
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab: ti
Date: g �Z �'�l
Certificate of Completion
DI.iner:
EHS/Date
Well Driller: ►�i/L�t't�
Pump Installer:
Approved by: �cv� �1 , St-�'�'s�i
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmentai Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
DAbandonment:
Date:
• Method/Materials:
License #:
License #:
Date: �-31-�5
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
���. s.f ���..� �.�
` �_ � � ����
I���aa-��.� ����.Il IE-3L��.Il�I�
Applicant: �� � ��
Location:
v s
Operation Permit
System Type (From Table Va): -2
Type V& VI Expiration Date:
Tax Map ��� arcel � ` �
Subdivision �2 SR.v-�
Phase/Section/Lot #
# of Bedrooms `�
Product (IIIg): � � 1 q`� �
Type V& VI Renewal Date: �, c�
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.
� � vv�C�
�
(Authorized Agent)
� �<
A I�
(Licensed Contractor)
�
Scale 0 vSZ-
PCFiD, rev. 12/14/12
� ��`�
(Date)
� 11
l
(Date)
��S���t
1 r
j�s�1� 3-2c�"�S
�
P�r� �..� -� �.�.
e�� _��
3-3�-�s -"��`�'
.�
Tax Map: Parcel #:
Septic Tank System Checklist (Type II-I�
Se tic Tank nitiaUDate
State ID & Date: �'— -� 3- z
S� ��tz.
Capacity: j �-U
Tee and filter
Baffle
Vent
Riser
Outlet boot
Perm. Marker
Distribution
D-box (levels set)
Serial
Pressure Manifold G�2 -l5
LPP
Notes•
System Type: �`�/'�
� Nitrification Lines InitiaUDate
Trench Width: �3 ft. � Z y-is
Trench De th: 38" in.
Tota1 Length: Zo-o ft. t/
Minimum s acing: g' ft.
Rock de th/ uality —
Dams/ste downs --
Crrade (< .25" in 10')
Cover 6" minimum)
Setbacks
From wells
Pro erty lines �/
Foundations!basements
SurfaceWater
Other: �
Pump System Checklist
Contracted Certified Operator (Type IV Systems):
Notes: N�itit�' Vo� n'luu�� v�., S;c� o�- �QuS-E'. �'IA��r��/z, e�t ,���n,n
: �„ r,,�ec
,� .
_��. ss ���..� ��
' �-�-- C� � �T�T��
�`.'4 na�na-�aa�nra��n��.Il ����.�.�1ia
Applicant:
Location:
System Type (From Table Va):
Type V& VI Expiration Date: ,
Operation Permit
Tax Map � Parcel #• i� g
Subdivision
PhaselSection/Lot #
# of Bedrooms
Product (IIIg):
Type V& VI Renewal Date:
This system has been instalIed 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)
`�^ c� ��f�v �-' �
�� Vl
(�� �
��
�lp
�
, ►�
Scale N% �� v
PCfiD, rev. 12/14/12
�
\
/
�
(Date)
(Date)
� �`
�� � \
��_ V \
�- � i��dc� �.� (
�
s s�►�
�
Tax Map:
Parcel #•
Septic Tank System Checklist (Type II-I�
Se tic Tank InitiaVDate
State ID & Date:
Capacity:
Tee and filter
Baffle
Vent
�Riser
Outlet boot
Perm. Mazker
Distribution
D-box (levels set)
Seria1
Pressure Manifold �
LPP
Notes•
System Type:
� Nitrification Lines InitiaVDate
Trench Width: � ft.
Trench Depth: in.
Tota1 Length: ft.
Minimum s acing: ft.
Rock de th/quality
Dams/stepdowns
Grade (< .25" in 10')
Cover 6" minimum)
Setbacks
From wells
Property lines
Foundations/basements
SurfaceWater
Other: �
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back plug
Haxd wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Mani%ld
Number of taps:
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes:
Tank Com onents InitiaUDate
Pump model:
Block (4")
Nylon retrieval rope
Float tree and attachments
On/Off float swing: in.
Alarm float (6" se aration)
Anti-siphon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
A proved and s'ecured riser
St� 1 Line '
Size and material: in. sch.
Length: ft.
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