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Applicant; �
Address/Location:
s�..�_ a'� �
Permit Valid for:� ve Years
Type of Facility:� �k� ���
Number of• Bedrooms � / �
Proposed Wastewater System:
Proposed Repair: ���
�
Impr Qvement Perrr�it
Non-expiring l\
New � Addition
�/,Employees / Seats:
Permit Conditions: J e� �i'� s k-e. �C h
Autherized State Agent: �
(X) Owncr or Legal Representative:
Taz Map: 2 Parc 1: a��l
Subdivision ,� � vt
Phase/Section/Lot # �Si
�
V4'ater Supply: �� ��
Projected Daily Flow: 3 D gallons/day
Type: �� P
Type:��..�
Date:
Date:
The issuanoe of :his permit by the Health Department does not g�:arantee the issuance of other required permits. It is the responsibility of
the applicant/property owner to insure that all Person Gounty 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 Improvemeni 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
a�td Rules for Se►�a�� Treatment and Drsnnsal Svstems'(15A NCAC l8A .19U0). Neither Person County nor the Environmental
Fiealth Specialist svnrrants that �he septic system rYill cvntinue to f�nciion satisfactorify in the future, or ihat t�e water sapply wit!
remair potabfe.
Authorization to Construct VVastewater �ystem
See sit2 plan and additional attaehnients �`).
x
Proposed Wastewater System: ���5 �q,�� �1um� (*)TYP4".=,�'—y� � Design Flow ��P O_ gal./day
New � Repair _ Expans�on Soil LTf�R: �� c'� gal./day/ft2
Type of Facifit-,�: �ji�jl� �2� . Bssement: � Yes _ No
(*) System Types Illb, lllbg, IY, and v, require periodac sys[em inspections by th.e Ferson Counly Healih Department.
Wastewater System Requirements
Tank Size: S�ptic Tar�k � d� gal.
Drainfield: Totai Area (�10 sq. ft.
Trench Width � ft..
Distributioa: Distribution Box / Serial Di
S�ecifications:
Pump Tank l �� � gal
Total Length 2 d 0 ft.
iVlin.Soil Cuver ___�Q__ in.
/ Pressurz
Grease Trap � gal.
Max. Trench Depth �6 in.
Min.Trench Separation I�__p__� ft.
l�
fluthoriz.,d State Agent: ���� Issue Date: Z—(R"��
Permit Expiration Date: Z—C —ZO
T'he s stem ermitted is:'Convenitiona� /Accz ted / Aiternative / Innovative . I accept the co�iditions
Y P P
and specifications of this permit.
{X) Owner or Legal Representative: Date:
Person County Environmental Health, 3?� S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12)
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WELL PERMIT
(New�, Repair_ )
Tax Map: � Pa cel: �5
Subdivision: v'�
Applicant's Name: {gc�� �o S�
Mailing Address:
Phone Numbers:
Location of Property: S
�� Fs
Lot: �
Per`nit 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/Comments:
Permit issued by:
�New Well:
EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comments:
Date Sample Collected:
EHS:
Person County Environmental Health
325 S. Morgan St.,Suite C
Roxboro, NC 27573
Date: Z�CQ—f
Certificate 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
11/26/13
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IE:aa.-v�a.ar�m••••,•,,-„�eaa�aat 7H1[�.m.JL,EIIa. Owner: I ►�'C-
Tax Map: �2 Parcel #: Z� 5 Date: 2'1�t—� S
I.ine Tap Tap (Sc�a) TaQ �lo� I,ine �,eng#h �odv /��ot
# I)iameter(�) ( m) �;, (ft)
1 3 $�O (�- o � � �o
2 3 0� p. So� .2�
3 3/� 0 10• Sa� -Zo
4 3 0 0, a' .�o
5
6
7 Z �i- p
8
9
10 �
n a ft of line x 65 gal. per 100 ft=� a �: 100 =� gal
75% x� gal = I S o ga1 per dose �f 3 gal per minute ( g pm) = I�'low I$ate
I+'riction �ead �
I,oss: • 5� ft per 100 ft of supply line x~���� ft of supply. line =100 = • U ft
. D ft x 1.2 = I� ft of friction head
Manifold Siae: �_" Force Main Size: 3 " PVC
�otal Dpnamic �$ead =�o ft of Elevadon head + 2- ft of Pressure head +� 1 ft of
Friction Head = �0 3 TDH � n
� Q.�'�� � R9�'J
Pump �tequi�ement: � GPM @ � 3- ft of Head
Drawdown: (° al per dose ;xl'gal per inch = S`` inch dra.wdown per dose q�l YDX �
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�ea�1 IBesiga �ffor�a�ion
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r�wtltm�e.
7owi/me�me
g�oe� I � S �
ifoid Siz� / � Taps
Max �To. Taps off one side
ace by �z :or iappin� hoth ;
��.,a 3/.» tans � 1"
3"
c�� i6 9 �
�„ �}�.�. 2 i 12
. . . _ � ' �`iow er TaP
Sixe �lltuerial F(a:u GPv!
?; " Sclted 80 �.�
�. " Sc}ied 10 ".�
;, °• :icl:ed 80 1 � 1
=S " Sciied ?0 1? =
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��cav�^n�r��n.�rnn.�aa��an.Il. ����.Il.��a
NEMA 4% Simplex Coatml Panel
+4" X 4" Pressvre Treated Post�,,j ;
Sloped To Shed Water 12" Sep,vration
\ Electrical Cox�it ^
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6" Covar • ' � � Access Cover• � •• . . ". ' '� .
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Izdet Fmm Septic Tank
+1" SCH 40 PVC Pipe '
�,, Opening Filled With � pn{i Sipkon Ho1e' •
PortLand Cement Cn�out �� �� �
Cl,eck
• �Ialve
Higk Watex 111axm Level
(6" Separatien)
.. » High Level - Pump On -.�,�`
;. ;: � � �� fiVaporLock
Hol�e �
• .� Draavdrnm �p H��
• •Low Level -Pump Ofi --�r'
i.• S
�•: ' P:ecast Concrete Taztk
;•; (MateaalStrengtk}3500
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T�x M�� � P�rcel # . �'
S�ihcllivision • �• �
Ph:�•s�e Sc�ct�ion Lot # - ;
Duct Seal Hoth
Ends OfThe Cozu�sit Conez�eie Riser •
—�- Z4" Mininnun
� � � � � � 6" Sepazation
Tlueaded Gate Valv�e •
IInion . •
' • .' %r..J•;1' .
;�.1-Pozt]and Concrete Crrout
Mastu � • - •
Zip Coxd • y� � Opening Filled Witk
'r� Supply ' ' portland Cement Gxaut
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4ntlet To Distnbutiox
:(.Nrlon 2" SCH40PVC Pioe
4" Conesete
�I) $lock
.: ;•, : , ,�.
1e F7oat Wizes . � �
.;
i
Flaats . �,
�Rem.ovable '. : '
F7oat Tree �•
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'�.�•°1. '.' ,.
� c� � GALL�N PULV�.' TANK
� ':.
PUMP EtATING � �
Pnenp Hus Be Ra t ed To De 1 ive r
� �3 Gallons Per Minate,
Agaiast _ f�3 Feet QE Tota.l
Dynaiaic Head (TDN) .
PUMPLINE TO DRAINFIELD 16A
SEE PLAT CABINET 16
PAGE 491-496
FOR PUMPLINE DATA.
3"PUMPLINE INSTALLED FROM LOT
TO OFFSITE DRAINFIELD AND
RREVIOUSLY INSPECTED BY THE
PERSON COUNTY ENVIRONMENTAL
HEALTH DEPARTMENT.
REFERENCE IS MADE TO THE
RESTRICTIVE COVENANTS RECORDED
AT DEEp B00K 856 PAGE 428.
3" PVC CONNECTIONS SHOWN ON
THE LOT AND DRAINFIELD ARE
APPROXIMATE LOCATION ONLY.
WEILS MUST BE 50' MINIMUM SETBACK
FROM ANY DRAINFIELD AREA OR SEPTIC
PUMPLINE EASEMENT.
WELLS MUST BE 10' MINIMUM SETBACK
FROM PROPERTY LINES AND 25'
MINIMUM SETBACK FROM THE
BUILDING FOUNDATION.
CONSTRUCTION IN THE PROPOSEO
BUIL�ING AREAS MUST MEET ALL
PERSON COUNTY SETBACK REQUIREMENTS.
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CE \
27A
3" PVC
CONNECTION-
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INSET DETAIL
DRAINFIELD
28A
SCALE 1" =50'
� 8A
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12�
PUMPLINE
EASEMENT
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LOT 28A DRAINFIELD
DATA
LINE BEARING DIST
L-147 S01' 32' 58" E 41. 16'
L-148 S06' 13' 98" W 43. 37'
L-151 S73' 32' 43" E 21. 25'
L-155 NO1' S2' 37" E 25. 60'
L-156 N78' 33' 45" E' 75. 92'
L-157 S 17' 03' 19" E 35. 17'
L—.158 S 19' 27' 06" W 37. 29'
L-159 S83' 49' 20" W 14. 09'
L-160 S 13' 25' 27" W 72. 82'
L-161 N68' 06' 28" W 27. 42'
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1Vame : � D S� , Ta$ Map #�Patcel # �� �
;Si�'` •sio� ' '� -� v `. .. Section/Lot# aSl
�9- /S
Authwy2ed State Agent Date
System componemrs �ejive.re�rt appmarinrate�canmurs anly.' Tha canhailbr mrase,�lag the systemprior to
begrnning ths ms�rrAahbn fa r�wne fhatpropergrade rs maintaned
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