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� UcforC insta!lirlq, �y5fc.m� �a^��c-E� ��nnin�s Survcyo�'S Shcu.td �c �on�ac,tc,d �x
Inc.a,�c SyS�tn•, %oc�ndari G�.
� O�cc, %oundar:'c� art, 2c- �Su�.bli5�c.y� Fla� 5}�S�m o� Cou�to� i� speci Fi�cd tz�r.a,,
��f SQacc i� a PrObltm� �ar��, drain ��c`c.Klc-S�apc�#� Ma�� �ic F►'Efcd � �c.(ocatcd� IS-LO•
Fur�.hcr at�y From ,SyStcrn Gt.r�a �a�a-�, ��c So�15 IoSt by fi�c t5 .�-�cl�
1Ma�f bc l.�k.i i i tLd, �-3� ... �
Cornbi�a-Eio/► �rcSSt�rc Mani'f��d���-p��a�S. Follo�
� �nskat� 5y+��m �n arca, . �
Mani �o td d- Pccn�P �p�= i F+'ca.t� ons P�flvid�d, , �� d'
. ��1.
� up5lop� d�v�rsion d� �c�, t'c�ui�cd . . . ��� \
3Q" dct P�acc o�ftct w/ c.Avt� ��c� �nd r'n d ra;n ��
��Fao� W�dc� �. ' �,':\
j,�u���t� f inc. 1'�uc.� �Dt, �.rcn�kcd ac�uss -�l�c �c�air arc� at � 5�+�►(ow
dcpkh 12-E��, �a�� � ��
��c �o �ow-ly jn� arc4� .V�r�.�c{;�! cr,�.t� �t��P �
� Ta�� �o����+�� to bt �s S�aWr�. �
an.cCS �j.' Fror�n 2� vcr�fcat Ct,c�• ��t[� fav�1GS j�� mi�a�€,cr.� �
2d�c Q� 7 • �. � . . :. � 1��
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kkrn a�o�.n� area S�a�.ld not erit�0�z� t�'�to ar-ca.. �.
QpriUct.�O��� an.d . , � �„
fl�ccss�r� �t2r �cp�e. �-. ��.r��O tanc�s� . `o
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mQ �� t��t � 1 Z Cd� i n�.� c�o+nw� c to 1 i Ft 2 FF/ucnt �"` ���
� �}; �� i n dtr p�c rr��„� y
c�c. �ar��, uc. t� SPa�.t conS►�t,rati�ns !i�"o0 �atl�r� ���'� t� �
5 pt �
. jl��.t t Dt, rc u.�re.� F� r.�tf��n� Purp�s�s. ��Sta l�� a Z�a�e;( M�c�t
�� '� � l�cr �`n t�c. Ot,��(�t. zn� ��' E�c. St��1c. Tk�� �
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o a r �idtd ovcr � 3�m d�+�c�fr 4rtc� 5�o Prwcstt �.ro5e ��.
�� ��Q�hd G vcr ��uti bc p o Y .
ia Kc�p a�l p�.rts oF �ScP��ic.�.CpO' rninimu.m Fro�n t.�c.11., .
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See A[tached �eet Fot Electrical
S�ecificatiaos
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lJndergrocmd Cable In Ca�d�sit
Nith Svicable Sealer In Both
Eads Of Conduic
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d. Dianeter Sched�e 40 PVC
..a pi�
• la1 R�ap � �
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' • Gate Valve
� 'Ih=eaded U�ion
- . Q�edc Valve
3/26" Syp� Breakes iiole
' � �r� gt�s � AxaBr.l Al1 CL�tis
� lllarm F'loat (eievation)
"Pu� on" Float Iel.evati.on?
' • "P�s� ofP' Float (elevationl
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pUMP RATING
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PUMP SYSTEM DETAII, SSEET �
pu�paust Be Rated To Oelzver
a Gallons Per Hinute
Against o�'1 Feet OE Tota
Dyaaenic Head (TDEi) .
S+�e Following Sheet For
Additioaa! Specifications,
Notes, And Esplanations.
0
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D� Do�U(lo� 7 — f3 '�1
Grout Log
Owner: �_ / j l�Z r� vu l _ Tax Map � N Parcel #�
Location: r9�-F o.F �L�t ���s � ' l c
Subdivision: � � ti, (�.. s-�,.� � Lot #
T-
Well Constrnction
Distance From nearest Property Line (Minimum 10 feet)
Distance from Septic System (Minimum 60 feet)
Total Depth: �,, 7� ft Yield: �� GPM Static Water Level: � ft
Water Bearing Zones: Depth ys ft ft ft ft
1�0,g^-�
Casing:
Depth: From �_ to � ft. Diameter: �� in '
Type: Galvanized Steel � �
Weight: Thiclrness: ./ b'� Height above Ground: � in
Drive Shoe: �Yes No Any problems encountered while setting casing? _Yes �o
If "yes" give reason:
Grout: �
Neat: Sand/Cement ✓ Concrete GraveUCement
. Annular Space Width inches Water in Annul Space Yes �No
Method of Grout: Pumped Pressure Poured � Depth to Ft.
Materials Used: �-r (jt.Ss
No. Bags Portland cement i.,�.��ti Weight of 1 Bag �� Pounds
If mixture (sand gravel, cu '+ gs) — Ratio to
ID plates: �es _ No 4 x 4 slab ✓Yes _ No
Liner:
From
Depth: Date Installed:
Drilling Log
To Formation
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(� M � 'C.
� /) � !'�_u ��r_
Grout: Installed by:
Location Drawing
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I hereby certify that the above information is correct and that this well was constructed in accordance with regulations set forth
by the Person County Health Department. _,,� �
Signature of Contractor
ID # ,��!QZ�( Date _,%—_Y, -l��i
Pump Installment
Pump Installation Contractor: �� c n�� �..% G jl ��c--. State Registration Number: �� ��%
Pump Depth: /v:U ft Static Water Level: �� ft
Pump Make & Model: J� e�� �-_ �� -� l^:: r_ �/�, Pump Size and Rating: .� hP �Q_ gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of this record has been p ovided to the well owner. .
Pump Installer Signature �� Date: %`3 -��/ PCHD rev O1/27/04
ano�ication [�ata: g J' 6'3
Amount Paid: �26n • ��
�?e�tQt �: �.7A 7 /
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.��PUCAi'lON FOR SERVIC�S
iax �aq �: �" �1
�arc21 �:
9� Ti-IE IPIFORMi�TiOPI IM 'ii�iE APPLICAT90M FOR AN IMPROVE31AEfVT PERflli1T IS IRlCORRECT, FALSiFiE�,
C�iAit�GED OR THE SITE IS ALTERfED TFiEi1� THE IMF�ROVEMEAIT PERIVi1T AfVD AUTHOf2lZaeT1�IN TO
COIVSTR4JCT SHALL BEC�ME If�VALID. .
� Permi$ r�ques#ecl by: (Ownerlag�n�l rospectiv� ow�er): � �`T/'��� `� L� <�.
) Home Phone: � /� Address: �
iusiness Phone: � � ^
2) Name and ac9dress of.cu�nt owner:
�-��
3) Praper�y Descriptioe�: Lot size: fr �- Township:
Directions to the properiyi(lncluding road�ame� and
y�
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�ot # �o �`'
' '- �.C% � /L UG � ' � ' h'"( CJ.�G /�G�2.
. % �//Gl �iM1. �iU��y �� a/�%"t �g �/ /a
�) Proposed Us� a Structure d]�scr�pt�on: answer eac of t� following questions:
a) Proposed Existing Type of Structure: Width:� Depth:�
b) Number of Bedrooms: � Number of occupants or people�to be se�ved:
c) Basement: Yes �/, No _ Wili ther plumbing in the basement? •
d) Garbage Disposal: Yes , Na
5) 1IVat�r Supply'Py�e: Private (new _ or existing,� , ubiic , Community , Spring
. Are any wells on adjoining property? Yesf/ No _ If yes, please indicate a�proximate location on the
� � site plan._
6) �oes your properEy contain previousty identified jurisciictional w+et[ands? Yes_ No_,
�LEASE NO'i� 'THE �OLLOWI6VG:
➢ A Pl..AT OF THE PROP�ERTIf OR SITE PL�►A1 MUST BE StDBMI�i'�D W{TH TH1S APPLICea�TiQN.
9 PROP�RTY LlNES Ai�lD CORidERS �VIUST BE CLEARLY MAR�D.
9 THE PliOPOSED LOCATIOM OF ALL STRUCTURES MUST BE STAi�D OR rLAGGEI2.
9'TiiE SiTE MUST BE 9iEADILY ACCESSIBLE �Of2 ,�P! EVALU�►TiOP! �Y THE HE�►LTH DEPA►RTMENT
STl�1FF. �
I hereby make appiication to the Persan Co ty Health Department for a siie evaluation for the on-site sewage disposal
system for. the above-described pro e�-ty. gres that the contents �of this application are true and represent the ma:.imum
faciiiiies to be pla on the pro rty understand if the site is altered or the intended use changes, �ie permit shall
become inva '
�
Owne r Le al r enfative Date
PCND, rev. 06127/02
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SITE SKETCH
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Tax Map # � �q Paxcel # ��
Section/Lot# ��
��� �;'��
�Authorized State Agent Date
Systena con�parte�:ts represent a,�iproximate contours o�ly. The co�tmctor must, flag the system prior to
beginning thc� iristctdlat�ton to insu�e that propergt�r,rie is maintaine .1"
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Scale: " � '
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S,�,qi� �c:l rs! ��,
•�MO�y� dfaiP� 'E.0 �1( � �Icd W�C�ce+n S01 �
Oncc P��'flcd,no s�<�„�� �;
d�0`1�` -�� ���
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PCHD, tev. 0�/12f 01
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I���aa-��.,,-„-,, ����.Il. IHL��.Il¢]�..
Applicant: III ;(,�ur n(,L�'
Lo�atioII: S7 hJ 2 Canco �d �
� S cr�
rc5 Lo� on
Road . (J /YILGti�
�rc� SuS� Poin
I � � �
Ta�x M��E� � P�rcel #
S�uhclivi�5•ion � � ��
Ph���se Sect�ion Lot # �
Improvement Permit
Permit Valid for �Five Years No Ezpiration /
Type ofFacility: ►`ny /c, Fami'iy �pwc//��� New V Addition_
# of Occupants �oma.x # of Bedrooms v� rn�.x Projected Daily Flow 3(n O
Proposed Wastewater System: Pun�� �nneva-�'�� �S�a rcduc�+'��
Proposed Repair: u.r►�,p �nno��c� v� ( a 5 q� 2�dr,�.��i on
Permit Conditions:
nroJidcd c��
Owner or Legal Represe
Authorized State Agent:
5
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c
Frc
r� i2o4d
Water Supply �i`�aEc wc- f 1
g.p.d.
. Type: � (3
Type:
o cJ
r f:7'h
Date: / � - � —" 3
Date: /a�8-c�3
The issuance of this permit b}� the Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This
Improvement P.ermit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownerslup of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Systems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
Specialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain
potable.
Authorization to Construct Wastewater System �Required for Building Permit)
* See site plan and additional attachments (�.
ProposeJ� Wastewater System: �L� m/� 1nnoJu�� uc. Type ll (�Cz Wastewater Flow �u�o� g.p.d.
New V Repair Expansion 5oi1 LTAR: . oiS g.p.dJ ft 2
Type of Facility: si nti 1c Fam � �y Qt,a c. ! l i nt, Basement i/ Yes _ No
���� ���D � Wastewater System Requirements
Tank Size. Sephc Tank: ,�6C�ga1 Pump Tank: �► �O gal Grease Trap: lJ1A g� Lo�,J
Drainfield: Total Area: � O � sq ft TotaI Length �� ft Mazimum Trench Depth � o� in 5 ti��
Trench Width 3 ft Minimum Soil Cover: �D in Minimum Trench Sepazation: � ft
Distribution: Distribution Box Serial Distribution V Pressure Manifold
'�O I d �iD.cC. l Fr cu.�1 �
Authorized State Agent: ��(.� I�i(.C.f�
Permit Exmral'on Date: 1�- i� -O
r /
The type of system permitted is Conve 'onal i/ Innovative Alternative.
the permit.
Owner/Legal Representative: � Date: _
�►J
Date: �a ' � -C�3
I accept the specifications of
2—�5—`�3
PCHD7/30/2002
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T�x M�p • Parcel # �
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Su.bdivision �- ' y
Phase Sect�ion Lot #
Applicant: �i� .ff���dC�� �
Location:
Operation Permit
System Type (In Accordance With Table Va):
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIAN
CE WITH APPLICABLE NORT�
CAROLINA GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE IMPROVEMENT PERMIT AND CONSTRUCTION
AUTHORIZ TIO..
r� �-as-a/
Authorize ta e A t Date
Installed By:�� -'//� Date: 1,����� � '���-�b_ /�T.d/��l'�y
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IE:����mm�� ¢��. 1HI��..]L,�. Owner:
Tax Map: � Parce] #: Date: (v d_
�.ine '�ap Tap (�ch) Tap F'!ow I�ine I.engtti Flow / foot
# Diaaneter iai) ( m) . ft)
1 i! b d/ 7
2 U �'o - S � /
3 ��Z �� / lo � � ��'
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8
9 b
1.0 /_
- ft of line x 65 gal. per.100 ft= : 100 = gal
75% x ga1= gal per dose gal per minute (gpm) = Flow �te
�riction I�ead
Loss: ft per 100 ft of supply line x ft of supply. line = 100 = ft
ft x 1.2 = ft of friction head
Manifold Size: " Force Main Size: " PVC
�otal Dynamic �ead = ft of Elevation head + ft of Pressure head + ft of
Friction Head = TDH
Pump Requirement: �,� GPM @ � ft of Head
Drawdown: gal per dose = 21 ga.l per inch = inch drawdown per dose
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"I"�e of Wat�s� Saro�fl�r: � Individual Comn�unitp Public.
�.��a�eants.
Site Approved bp /�? ��
Grouting Approved bp,�.� %�9--0�
�lell Log `�
�Tell T
� v�n.t v CS &o^� ��
Hose Bib ✓
Concrete Slab ..✓
�el�.�proved
n,�� - g.2S ��/
C� �
Datc: � ZS'--�i
�tac�� Sa� S�ch�
Wells must be 10 fest from propertg lines.
Wells must be 100 feet from septic systems. �
Wells must be at least 25 feet from anp bwlding fouadation.
WC( I 1c0�
,'c. SvsktM , .ins-E�II i� arcc, s�,�[�n,
PCF�, rev. 09/07/02