A24 208Application Date: j s t r p� �_� �j -� I� � i S��; � Tax Map:
A moun t Pai d: • Q 0 0, O U � a 0 0. � �� a P a r c e l #:
Receip t#: (� 4 3� 4 I 7 6 d �-�-°` l� 1� i 6 �'� l 2 r�'�4 0-�
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Application for Services (Septic Systems and Wells)
1) Servic ques ed �—
Name: � �
� �`;�•'- J� Phone # (home): 33� ��% ��'�%��-�
Address: �`� S. � Lr (work/cell): 33 � r'
r � n�. . v� O� �pi (�C�u.,��t.wt �
ner if different than a licant : ��r'_`�
2)Name and address of current ow ( pp )
Name: ��' cy vY.� .
Address:
3) Property Description:
Address and/or directions to
Lot Size: Subdivision:
4) Proposed Use and Type of Structure:
Residential 1�. Business/Type: Other
Number of bedrooms .� / Number of people served (seats/employees):
Basement: Yes � No (wi�plumbing: Yes No _�
Garbage disposal: Yes No `
5) Water SupplY:
Private Well � (Proposed� Existing _�
Community Well: Public Water System: .
Are there wells on the adjoining properties? No _
Lot #: j �� 31
Yes '>C (please show location on site plan)
Note• A completed application must also include:
➢ A pladsite plan of the properry thai shows properry dimensio�s and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property 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.
t'� `
Signature (Owner/Legal Representative): �-- �j Date : � � �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Applicant: � �
Address/Location:
s1� a� Q�
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Improvement P�rmii
Permit Valid for: Five Years _ Non-expiring �
Type of Facility: fe PS � New iC Addition _
Number of Bedrooms �/ Occ�ants�/ �mployees / Seats:
Proposed Wastewater System: f0 �.�'rqp (YI�Y��- 02 �✓ � ur
Proposed Repair: ►-i �'' ri q a�-,' o,^
Permit Conditions: �22 Si� '% �� � �t
Taz Map:6'�t Z Parc : ZJg
Subdivision rv�
Phase/Section/Lot # 3 (
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VVater Supply: �� ��
Projected Daily Flow: 3� d gaIlons/ ay
►P Type; �
Type: �_
Authcrized Staie Agent: ��dlw� l�. �ja"��✓ Date: L Z
(X) Owncr or Legal Rep sentative: Date:
The issuan�e of this permit by the HealLh Department d�es not g►:arantee the issuance of other required permits. It is the responsibility of
the applicanUproperty owner to insure that all Person Gounty Planning and Zoning and Buiiding Inspections requirements aze met. This
lmprovement Percriit is subject to revocation if the site plan, plat or the intended use changes. The Improvemeni is not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina °Luws
rr�td Rules for .�etivag� Treatment and Drsnnsal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental
Health Specialist iv�rrants that :he septic system rvill continue to f�nciion s�tisfactorily in the future, or ihat t�e water supply will
remain poiable.
Authorization to Construct Wastewater �ystem
See site plan and additional attaehnrents ("`).
�
Proposed Wastewater System: �� +( �" �' r' W/�IYvI�? (*)Typ� � Design Flow 3�v �_ gal./day
New � Repair _ Expansion _ —� Soil L'ff�R: , O gal./day/ft�
Type of Facilit-,�: 3�1�� S. Bssement: � Yes _ No
(*) System Types III6, Illbg, IY, and V; reyuire periodic system inspections by the Ferson County Healih Department.
Wastewater System Requirements
Tank 5ize: Septic Tar,k � � � gal. Pump Tank � S�� gal. Grease Trap � gal.
�'r �pul—�r �
Drainfield: Total Area n q sq. ft. 'fotat Length ��_ ft. Max. Trench Depth �_ in.
Trench Width j� � fl. iViin.Soil Cuver � in. Min.Trench Separation �� � ft.
Distribution: Distribution Box / Serial Distribution / Pressure Manifold �
S ecifications:_� u � ��Y (�L�� � Jk�-'�S� ��� Sn� � � ✓�"'e'e�C�
i S so �� n r au� D�J C a Cc� � �, , '� 5
c ra i �P �- � f. w�;
Authoriz.,d State Agent: Issue Date: Z 2�—1 S
��D�t �� Permit Expiration Date: `2—Z S– 2 c�
T'he system permitted is: Convent�onal �/Acczpted / Alternative / Innovative . I accept the co�iditions
and specifications of this permit.
(X) Owner or Legal Representative: Date:
Person County Environmental Health, 32� S Morgan St, Suite C, Roxboro, NG' 37573/ph: 336-597-1790 (rev 5/12)
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begrnning ths installah'on ta i�qs!+ne fhcepropergrrrde rs nruintor'ned
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PUMPLINE TO DRAINFIELD 16A
SEE PLAT CABINET 16
PAGE 491-496
FOR PUMPLINE DATA.
3"PUMPLINE INSTAILED FROM LOT
TO OFFSITE DRAINFIELD AND
PREVI�USLY INSPECTED 8Y 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.
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
BUIIDING FaUNDATION.
CONSTRUCTION IN.THE PROPOSED
BUILDING AREAS MUST MEET ALL
PERSON COUNTY SETBACK REQUIREMENTS.
CE
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15'
PUMPLINE
EASEMENT
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INSET DETAIL
DRAINFIELD
31A
SCALE 1" =50'
LOT 31A DRAINFIELD
DATA
LINE BEARING DIST
L-120 S87' 40' 18" E 26. 04'
L-126 N12' 41' 00" W 77. 92'
L-127 N54' 04' 42" E 91. 09'
L-128 N66' 24' 00" E 80. 48'
L-129 SOS' 56' 25" E 93. 93'
L-130 SO4' 59' 00" W 65. 67'
L-131 S70' 06' 38" W 22. 28'
L-132 N88' 06' 15" W 20. 68'
L-133 N88' 06' 15" W 71. 70'
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L=72.72 '�.
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LOT
TOTAL
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31
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RES
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So� SEe ��EA
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qREArNG
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WELL PERMIT
(New � Repair _ )
Tax Map �� Parcel: 20 �
Subdivision: �j-Q ��
Applicant's Name: �� jQc� SQ
Mailing Address:
Phone Numbers:
Lot: �
Location of Property: S�� Ol-� �(i ��S'7'�1-� I�CQ�
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/Comments:
Permit issued by:
�Tew 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: 2 —2 s � '?
Certificate of Completion
DI.iner:
EHS/Date
Depth:
Grout:
DA6andonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 Fax:336-597-7808
11/26/13
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1E.�-�� ��.��.]1 1[H1[�.�..11,E� Owner: � ""� ���`� � �
Tax Map: � Parcel #: 2� � Date: 2� 2 S�—[ S
I,ane B'ap Tap (Scfla) Tap �'lo;� Line Length &'�o�v / f�ot
# i)i�Yneter(�) ( �) ��. (ft)
1 Z �fo 7 �`o , t� B'
2 � z �Lo � ?• � � � Fr4'
3 � S'o 5�5 70� ,c�'7�
4 'lZ � 5• 5 ? v� � D? 8"
s ��z �o S� 5 7� � o� 8'
6 � 2 �o p' � o' �no ` . 0'Z
7
8
9 Z v�P��f�— o
10
L� � ft of line x 65 al. per 100 ft= 3�Z �� � ; loo = 3 i z$�
-�°h� x� gal =� gal per dose �_ gal per minute (gpm) _�+'low 1$ate
�o�
�'riction �ead �
Loss:--��ft per 100 ft of supply line x�' % tl� ft of supply.line =100 =� ft
ft x 1.2 =�_ ft of friction head
Manifold Siae: �_" Force Main �ize: 3 " PVC
�otal Dynamic �$ead = SO ft of Elevation head + Z ft of Pressure head +�� ft of
Friction Head = � z TDH
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Pump Reqiai�ement: � GPM @ �? ft of Head �
Drawdown: .�gal per dose ��'1'gal per inch =�_ inch drawdown per dose �1 �iQY° '
30
G�ePsl IBesiga� �for4na�ion
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Size IYltuerial Flo:c G�YI
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6" Cover •
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Ix�let FmmSeptie Tank
A" SCH �0 PVC Pipe '
NEMA 4X Simplex Contml Pastel
4" X 4" Pressare T:eated
12" Separation
Elect:ical Conduit =
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Suhcllivisioia ' � -
Ph:�s�e S�ct,ion Lot #
Duct Seal Hoth
Ez�ds Of The Conduit
-� 24" Mininnim —i
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Threaded Gate Valve
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• Access Cover• • ' ' • ti ;
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Portland Cement Gxout �� H� I
C�ueck
• Valve -
, High Water Alarm Level
(6" Separati�on)
High Level - Pump On -�.�,�
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• .� Drrxdarm �Up H�71)
•Law Level-Purnp Off ---r^'
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Precast Coz�crete Tank
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Concrete Riser
6" Sepaxation
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�pply Portland Cesncnt Grout
ix�e • • '
Outlet To Distnbuti�ox
2" SCH40PVC Pipe
1e F7eat Wires .� �
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Floats , ,
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PUMP RASING � .
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Agaiest � 2 Feet OE Tota.l
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