A24 199���.sf ���.���
�_ � � ����
I���a���,r„-„ ����.Il. IFZI��.IL�I�
Tax Map� Parcel # 1 Rq
Subdivision `Th�e QesPrv�
Phase/Section/Lot # ZZ
# of Bedrooms 3
Applicant: �vb �as�
Loca/t�ion: ;-I �1 >� o,., 2 io;� �.��e� G.u,,r�r 2� .? G o-� ehd +ca Kr C�
n._ 1/.'_nlL........�L riG�.LoC 5 �en./ �%� a�_ !t G-)'..% Q1 _ %/'/1/e�.�.,.��o nvn�.nt. /Li�o PiP
l,o� ah (�J �� cu(-de- �a�i . . �
Operatian Per�it
System Type (From Table Va): e Product (IIIg): he ��'c�
Type V& VI Expiration Date: Type V& VI Rene al Date: i,1lT
�� 7
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)
�e-�rac. Lew i 5
(Licensed Contractor)
a= �►^es
�►�,.�`ef�P
Scale �
PCHD, rev. 2/14/12
La1��-
�
(Date)
s/D �o w� (Date)
�; �?fio �-s:.�
�J�1� `�����
�� �
�vq � �-�;e C�
���� {-- 5y�i'�Y �'�� .�
S �-�a.QQ � �����t�
��
�_<<-t�- 55
� ��;,�.�ec�P ,Us,��c. `����
Line Length
0�
� ser
�c�
Total 2 0-0'
Tax Map: � Parcel #: � qG�
T-^r—
Septic Tank System Checklist (Type II-I� System Type: ���
Se tic Tank InitiaVDate
State ID & Date: - 2 �S -1 f-
Ca acity: 5-
Tee and filter ,/
Baffle i/
Vent ,/
Riser
Outlet boot
Perm. Mazker
Distribution
D-box (levels set)
Serial
Pressure Manifold $ -( � j
LPP
Notes: �- ( � -
e, f'n s ,1,,..I , _ ., �: ,,,,� n,.,.J ,�.� l, i —
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date: p = �52 _��-�
3-2-I5 �
Ca acity: PTS- 1575 ✓
Riser 6" min.) r/
NEMA 4X Box
Model:
Piggy back lug
Hard wired
Alarm functioning
Mounted on post
Above grade (12")
Conduit sealed
Pressure Manifold
Number of ta s: s �i . S�f-lY l
Size and sch: � ;
Contracted Certified Operator (Type IV Systems): _
Notes: � Y"l°�1�r��'�i D.� Sun���. �1 ��l-C I �tS
:Z
Tank Com onents InitiaUDate
Pump model:
Block (4")
Nylon retrieval ro e �
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
Approved and secured riser
Supply Line ��Q��C'S �vv <
Size and material: 3 in. �Dsch.
Length: � �op � ft.
�-
e�::c
�
�.��.sf �I��.���
�- � � ����
��rnwn�c-��n.�am�ra�.am.� g'���.Il��a
WELL PERMIT
(New� Repair_)
Tax Map: �Y Parcel: '�
Subdivision:
Applicant's Name: �ob '�o $JL.
Mailing Address:
Phone Numbers:
Lot: 2 2
Location ofProperty: Sf %� Q� �t9'C t� �S-N�� /�� ��d-�- �►� 1��
o " Ct�i— —SaC
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/Comipeats:
. .. �
Permit issued by: w�,� Date: � i�"l S
�Tew Well:
HS/Date
Location:
Grouting: �-�7-1 �
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab: �
Certificate of Completion
QLiner:
EHS/Date
Well Driller: l�Yw�
Pump Installer: �� � �
Approved by: ' y
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
Roxboro, NC 27573
Depth:
Grout:
DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date: �
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
SEE PLAT CABINET 16 ` •��7�� 1C"1ld1L�i,���
PAGE 491-496 `�' ��+ •
:�:������
FOR PUMPL I NE DATA . 7C���.�,���;� ����
3"PUMPLINE INSTALLED FROM LOT � �� `��'��'�.�� ` `
TO OFFSITE ORAINFIELD AND , • j/� � ��`�'�I '� ����T�H
PREVIOUSLY INSPECTED BY THE ►70� � . � ���
:::IV�aie
PERSON COUNTY ENVIRONMENTAL ' •• , .' T��P��, � � .P�cel# ��
HEALTH DEPARTMENT . ���� Y� Y 10 �' " Section/Lot## Z2 __
� Sf 1 — I �
1Yuthaxi�ed Sra t
REFERENCE IS MADE TO THE . �n Date
RESTRICTIVE COVENANTS RECORDED sy�em����,ieS��p��nu�;conmW►sonly' Theconiraclormrastflob.fhe,y,siem�riarto
AT DEED �BOOK 856 PA�E 428. begituiingthsmsi�rllationioimsrmethde ro sr rstna���oi�d
�. � g� .
3" PVC CONNECTIONS SHOWN ON
TNE LOT AND DRAINFIELD ARE '
APPROXIMATE LOCATION ONLY.
WELLS MUST BE 50' MINIMUM SETBACK S�6�, •
FROM ANY DRAINFIELD AREA OR SEPTIC .
PUMPLINE EASEMENT. �— �
j'�=5 �
WEI.LS MUST BE 10' MINIMUM SETBACK � �
FROM PROPERTY LINES AND 25' / � ,
� MINIMUM SETBACK FROM THE , __�r - ' •
BUILDING FOUNDATIOtJ. '" . /
. . � �
CONSTRUCTTON IN THE PROPOSED .. ' � �
BUILDING AREAS MUST MEEi ALL SEE
PERSON COUNTY SETBACK REQUIREMENTS. ROAD __ _-�� � r �,6�
---- ._ ___. ____ _ ___ _ _ _
DATA • '� IS
S�� � )'� _/DD � � IS v I CE 3�, ��0
C66.
�a� l l IS
�s
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0
WELL CONSTRUCTION RECORD
This form can bc �cd fa singlc or multiple w�Ils
1. Wdl Contraetor Informatioa:
lC .e / �h !�' �9�_-�,�.�f-�
Well Conaactw Name
� � 9�
NC Well Conasuor C«xification Numbcr
Barnette Well Drilling, Inc.
CompanyName n
Z. ��Cl� COI1ShT2[600 PtlTill� ii: /• ��� � l.� 1
Lisr a!1 opp(icable uell conunruion permiu (t_c Cmmry, Srmh Yario�e, ucJ
3. R'ell Use (c6eck wdl use):
❑Agricuitural OM�unicipaVPublic-
❑Geothamal(Eleating/CoolingSuPP�Y) �rstidu�tial.WataSnPPiY��P�e)
�IndushiaUCommacial OResidential Wat� SuPP�Y ���)
Supply WcIL
I �Aquifa Recharge ❑Gtovndwattr Runediation
' L]Aquifer Storage and Recovay OSalinity Barrier
OAquifa 7'est ❑Stonnwater Drainage
�E�uimentalTechnology �SubsidenceCoNmt
❑Geothetmal (Gosed Loop) OTracer
�Geothamal (Heating/Cooling Returo) ❑Otha (explain nndrr #21 Remads)
4. Date Weii(s) Complcted: — �(S Wd1 ID# ���'f '
Sa VVe(1 Locaeoa:
�� � ��se T�� �s e�u
Faciliryl�vner Namc Faa7iCy ID# (if applipble)
S��e��a� �Sf,,��L� �'t� /a�aw�.eF�-
Ylrysiral Addc�sa. Ciq'. and Zip
���Sc�aJ �"�� %
Counry P�cc1 IdcntificatiouNo. (PIN}
Fa 4decnal Use ONLY_
�a we�ruu �nHFc:
fG �2 �ft I tJ d�f �(� l 9
rc /�fn r` 3 raAl
0 �� 7a f�� �'%��J;
G INNERGASfNGOR7'UBING eotLdrmalcl
'ROM TO DLAMEfEB TF
. R.. R in.
R ft m.
T.'SCREEN :
,
'ROM .TO DIAMEfER . SLOT&C
R ft �.
fL it in.
B:GROUT ' �
ROM TO MA7TRIAI. -.. 1
ft �� ft �� ent
tc rc
ft ft.
tt R
(t tL
zuxc°r:os'atm� �aa�s�� s6�
1'O DESCRIP7ION
iG s ft Q v e�.
r4 3 v m d
� .SS� �
n- Z OD« �
� �
fL ft
fG R
�r3
Sh Iahtudc and Long�fude �n degreeclauuptes/saeondsor dwmal degrees:
(iwcU Sdd, onc Iallong is sufiic;wt) �' �:
36°3v � � � `�N 7g� a3 �'S�z" w �- /
� fCasifiaj d1 Gonttattor Dazr
6. Ls (arc) the wtll(sj: � anent. or or�poraTy gy s,�,,,g�� r��, ��y,� �.,,�f� ��1 �+��� N��
,�ir� rsn xcReoac.oioo � is.� xcac ozc.ozoo w�rr cA�r.v�� su,� m;a rr�r e
T. Is tfiis a repair to an uistiag:wdL• OYes or � dOpj'"O��IiLt RGOlQL2fbtlHEtMVH�2QlQ"!ItGWGII OW/1tT
Ijdeis /s a repotr, fU om Ib�own we11 eonst�pet�o? infornwtiai qirdr;pl6in the natruie ofdx
xpair wrder �21 rcmarkr sxtion o� ox �be. back oJPhls form. 23. Sit+� diagi9m Or sdditiooal Wd! dFrn;I�•
/ You may use tfie bacic Qf this pagt to pravide. additional wc�l site ddails or wd!
8.:1�Tamber of weils eoashveted: / cons4udion ddails. You aiay also.attach. additional pagcs if necessazy.
For mukiple tnfecrion or non-watu.ru�ly we!!s OIYLYwirh thc same eonsrive�iort, }rou aart �
.�a,��o,�fom,. SUBMII'I'ALINSfUCi'10hLS
9. Total w�ll deptfi below land sorCace: ��/ ( jtj 24a For All Wdls Submit this .fotm wi�hut 30 days of comple[iati of well
FormrJriplewellsG-stolldepduijdig'erene(amnple- 00•a�1(aj[00� odnstruetiot�fothefollowiitg:
10. Statie water level below top of casiug: Z� �ft� Division of R'atcrQuatits, Information Processirig Uait,
lJxnrerlevclls above casin� Yae ^+" 1619 Mxil Seryice Center, Rateigh, A'C 37699-1617
11. Borehole diameter. ���y (o,) 24b_ For Iniectioa Welts: In addition to sending the fotm to ffie addfess in 24a
��.,�/p �/ above, aLto submi[ e copy of this fomt withie.30 days of wmpldion of well
1Z WeR coostruction method: '/7 ]%� Oti. D TR %�. ✓J cnnshnCUion to the following
4i.a auga. mtazY. wble, diced Push, uc.)
Divfsiou of Water Qaalitp, Undcrgiaaod.Injection Con�ol Pragram,
FOR WATER SIJPPLY WELIS ONLY- 1636 h1a7 Servioe Ctater, Ratei�h, NC 27699-1636
13a. Ydd (gpm). O Mcthod oftes� B�own20 minute 24a Fot Nater. Sanblv & Iniectiun t'Vdlr In addition to sending the form to
HTH �O ���a? �OVf' �O �it one copy of this fonn within 30 days of
13b. Disinfection type_ �o�� '� �2 riUp �pietion of wdl consWction fi the wunty hcaftli dcpartmrnt of the co�nry
wtiere construt�e4
Fam GW-1 North Carotina.Deputmeot afFavimnment ud Naaaal Resoaress —Dirision oflVaux Qi�aliry
Rcviscd Jao. 2013
_��, ss ���..� ��
� � ����
lC"e��a�r-��ra�*-TMT ��rn��.Il 1�1I��.I1�1�a
Applicant: 15a�
Address/Location:
Tax Map: � Parc : ��
Subdivision �
Phase/Section/Lot # Z2
Permit Valid for: Frve Ye r:
Type of Facility: i��� •
Number of• Bedrooms 3 /
Proposed Wastewater System
Proposed Repair: ri
Improvement Permit
%L Non-expiring
:, New � Addition
�ccupants / Employees / Seats:
Permit Conditions: �.e S% � ,Sx-��C'�+
Water Supply: �✓���
Projected Daily Flow: 6 o gallons/day
Type: ��
Type: ��
Authorized State Agent: � U K�C,T Date: ?S�( y' /�
(X) Owner or Legal Re esentative: k a�a �� �y ,� � Date: ��� q� (�
C
The issuance of this permit by the Health Department 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
Improvement Permit is subject to revocation if the site plan, plat ar 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 North Carotina `Laws
and Rules for Sewa�e Treatment and Disnosa! Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist warrants that the septic system wiil 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: ���P� +�/�� �� Yi�v►�� (*)Type-�i�Design Flow 3�� gal./day
New � Repair _ Expansion _ Soil LTAR: . 3 d gal./day/ft�
Type of Facility: 3Y�]2 {'2�QS � Basement: _ Yes X No
(*) System Types IIlb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department.
Wastewater System Requirements
Tank Size: Septic Tank ��� gal. Pump Tank � S� � gal. Grease Trap � gal.
Drainfield: Total Area �0 0� sq. ft. Total Length Z� � ft. Max. Trench Depth � in.
Trench Width 3 ft. Min.Soil Cover� in. Min.Trench Separation � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �
Specifications: ,n_ �D �',o'�� 1 ✓1,5�{s!( � . �w�,e��PS �-Ps5 �'ti+a.�t 3 �P � � �-P�Pf�• �'��
Authorized State Agent: � � ��-✓ [ssue Date: '� ( Q- �S
Permit Expiration Date: � �Q�2d
�o��Tf ��(
Tl�e system permitted is: Conventional /�/Accepted / Alternative / Innovative . I accept the conditions
and specifications of this permit.
(X) Owner or Legal Representative: Date: `' —��
Person Countv Environmental Health, 32S S. Morgan St, Suite C, Roxboro, NC 27573/ ph: 336-597-1790 (rev 5/121
��`�, � ]PI��.� ��
7��-�.�� - � � �� .��..0 � Owner: � � "'��'� �
Tax Map: 2 Parcel #: Q Date: (-�
I,ine Tap Tap (Sch) Tap �lo� Line Length �ioe�v / f�ot
# i)iame�er(�) ( m) �:• (ft)
1 3 O L-5 0' •1
� 3 '� �• Q. So � . ZO
3 3 p �2. ` ./(o
4
5
6
7 Z h
8
9 �
10 �
n� ft of line x 65 gal. per 100 ft= h 4 .� : 100 =� gal
75% x Z o o gal = I S o gai per dose �_ gal per minute (gpm) = I�'!ow I�ate
�'riction �ead i
Loss: .�'o ft per 100 ft of supply line x�'.3�00 ft of supply.line =100 =%2- ft
� Z_ ft x 1.2 = ��7 ft of friction head
;� ��,�� I%�.�
(�k�+�,
� S� ✓`'(� �
Manifold Size: �" � I+'orce Main Size: 3 " PVC
Total I3yaamic �ead =�Qft of Elevadon head + 2 ft of Pressure head +�ft of
Friction Head = �TDH
� ���. �,Q
Pump Itequiaement: � GPM @�07 . ft of Head�� �
Drawdown: S.�gal per dose ;,�2�I gal pbr mch = L inch dra.wdown per dose ����q,
ZS
Cenea�sl Design �forffiation �
�� . ..t ..
, * ���' ����rs
_. is�� . , , ,.
i�iii�i '
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9am�
� �canv.��
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� � ��
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iiii�i++iiiiiivii�iiiii�ii+iii�
r`.**i��•'��i��iN��i�ii�i*a����:�*
� ��
� �..e����-
��C� u,�
2.l�u,vq (��✓�
� � � � � �1o�v er Tap
�we ilWrrs¢r-ial Flo:v GPYI
!.� " Sched 80 .i•�
�,' Sched 10 i-i
5, " :ic/:ed 80 1 � 1
'� ' Sciied 40 ? : ;
.l
`g'��y 7;�� ���� ��
~ � � � ����
7����-������.�,]L IE-��.�.Il�IIIa
. Sloped To Sl�ed Watez
NEMA 4% Simplex Contml Panel
�4° X 4" Fresstu+e Treated Post
12" Separation
E12CtI7Ci1 C017�11� �
e
i
b" Covar .� • � ` Access Co.ver , • . . `" � •� , v :
� � � - � � • ; i
.. , . � _ , .
, ., � ��
� • � r �' . _ _ : •. �' • � ;
�,. Opexiix� Filled Witk .`• Aaii Sipkon Ho1e� .
I�nlet Fmm Septic Tauk Portland Cement Gsout � ♦
A" SCH 40 PVC Pipe '
(n� H�
Cbeck
• Valve -
High Water Alarm Level
. Higlt ev�el Pump On -.����
;, � � ! �� '�Vapor Lock
� �p Drawdam Ho1e .r
. ., � `IIp �,
•Low Lavel -Pump Off �'�
,-;. : .
' Pxecast Cos�crete Taak
r; (Matesial St:e�th }3500
.� •, .
� .`': '� : � . ' _
T�x M��a t P�i�cEl # , �
Suhellivisioi,i ' • - '
Fh:��se Sect�ioi� tot #
Duct Seal Hotk
Endt Of The Conduit Co:tcreie Riser
�' 24° 1413t11t1A1:C1
•. . � . -• , . . , b" Sepaxatiax
Threaded Gatn Palne •
IInicn ,
' '• ' ; %�..t/•� :---��
,r,:..�--POxtiandConCretB Csrout
's. . �; Msstic � - - ' .
Zip Coxd �� � • "' - " '
'p� Supply . ' ; � • � Ope*�'� F�led With
Line . . � Portland Cexnextt Grant
� Outlet To Distttbuti�ox
;f.Np]on 2" SCIi40PVC Pive
4" Corcxete
_' .�� • �, . . �. ;
Float Wues � '
:. .
t. •r
Floats ; �;
E..Removable '. : '
Y7nat Tsee ' �
��
r� _ S. _ : ••�.
. • �_ . .
� SD � GALL(�N PUL11Il' TANK
�
, � Zd�l ��Qr i �( � fJ �
-Q-�/t� �IiQ �'�+✓!'�"
�,
PlMP EtArING � �
Ps�mp Must ge Ra t ed 7o De L ive c
� � Gallons Par Hinute,
Against �O Feet QE Tota.l
Dpnaraic Head =DK) .
v
��G �a
� ��� � � � �
� 3�3
��� � r�v�
r�a,;�
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