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A lication Date: a' 1 �'�� � 2t�1, � Ta�Y Nlap: �
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Amount Paid: 00 � 0 O ��. � Parcel #: �
Receipt#: � �3 �j-} �21;,�-7 �dvJe.�D�� �30-�
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Application for Services (Septic Systems and Wells)
Services Re uested
mprovement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of s stem ermitted)
❑ Mobile Home Replacement or Building Addition ❑ Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/�75.00 No CharQe
1) Services Requested by:
Name: �T� �U i ` � d�
Address: 'r-f� �' ` J�,' '
�-�r����`r` � � � � ���
Phone # (home): �.3�i "�J % % "G.� •�" 7�
(work/cell): ��.� E� . v �3 -- �>3 7 �>
2)Name and address of current owner (if different than applicant):
Name: � /
Address: ' /
,�
3) Property Description: Lot Size:/+ '� ` �" `v�, `-���N'`� Lot #: �
�� � �� Subdivision:
Address and/o ' ectio to Property: S�_ �� �i �" �-�:..�� �''L.
�� `f o! - G�.
4) Proposed Use and T pe of Structure:
Residential � Business/Type: Other
Number of bedrooms / Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes � No �
Garbage disposal: Yes �No �
5) Water Supply:
Private Well ✓(Proposed �xisting _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No _
Yes � ase show ,location on site plan)
Note: A completed application must also include:
➢ A plat/site plan of the property tl:at s/iows property dimensions and tl:e size and [ocation of all
proposed structures.
� A signed copy of the `Lot Preparation' form ver�ing that the properry 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 o i e site is subsequently altered, or if the intended use changes, all
permits and approvals shall become invali . `
Signature (Owner/Legal Representati e): Date :� � �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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property of
�� ROY CARVER
�S� �'1" Cunninqham Twp. , Parson County� N.C.
�, Jan.,1980 Stale 1"■100�
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tHyeo �ak•I �lvP ��' , Paul l. Bailay, RLS-1861, Roxboro,N.C.
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NOTt: OdJ coordinap� latu �.es w,r.r er uaon,
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VICINITY MAP
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DATA TABLE
11NE BEARINC D157
L- 1 N79'OB'O6•E 21.75'
�- Z N18'41'16•E 20.70'
LEGENO
NF • NAlL FOUND
NS O NAIL SET
IF • IRON FOUND
IS o IRON SET
o AIATHEMATICAL
POINT
UNLESS SIGNED. SEAIED AND DATED. THIS (S A
PREIININARY PLAT, NOT FOR RECORDATION, SALES
OR CONVEYANCES.
HAMLEfT—JENNINGS
dc ASSOCIATES, P.A. •�•
PROFESSIONAL LAND SURVEYORS
212 5 LAYAR STREE7 - PO BO% 1266
ROXBORO NORTH CAROLINA 27373
(336) 599-8742
�D�RM — �2 �C�c�2 l� � Ul�-.�
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P.e. 2{. P. 8{
wELL
AREA
{ZO'
CONTOUR
CAROLINA PONER
8 IiGMT LOYPANY
HYCO LAKE
PROCOSED BUILDING \
AREA
PROPOSED STRUCTURE.
SEPTIC TANK AND PUYP
SYSTEY TO BE NITXIN
iME BUILDING AREA
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,O 'q
: h�
�a 2 �o.
NELL
AREA
7
.57
PROPOSED wASTENA7ER
SYSTEMS AS FL�GGED BY
PERSON COUN7V ENVIRONYENTAL
. HEALTH DEPARTYENT
1.612
ACRES
L0T B
P.B. i�. P. 81
R d 5 CARVER PROERTIES, LLC
D.B. 668, P. 131
120'
CONTOUR
(F
SITE PLAN
JANIE C. CLAYTON
CUNNINGHAM TWP., PERSON COUNTY, N.C.
HAMLETT—JENNINGS & ASSOCIATES, C-948
212 S. LAMAR STREET, ROXBORO, N.C.
AUGUST 2011, NEAL C. HAA�LETT L-2465
�a
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g,yt �/1 inch � �0 /t.
NORT CAROLINA PERSON C TY
AL C. HAUL _T_____� �ERTIFY TMA7 THIS
I. _ ' '___ "_
SURVEY IS F AN E% ING PARCEL IOR PARCELS>
I1ITHIN _ PE_ 4N__ OUNTY AS RECOROED IN DEED BOOK
j,jz, P�GE dND/OR VL�T _8K_ _24_. P�GE _@!_.
ALl PROVi510N5 NORTH CAROLINA GENERAL $TATUTE
17-30 �5 A4E D GARDING TH15 SURVET HAVE BEEN
YET. IIITNES YY H� AND SEAL TNIS _ 2_ DAY OF
THAT THIS
ON FROY
AN A AL SURVEY YADE WAE 4Y SUPERVISIOfi '�
(DEED LRIPTION RECORD IN BOOK _Z�FZ_. �
PACE _¢2_ ETC.1f0TME ; TMAT TNE BOUNORRfES �.
NOT $WtVEY ARE CLEA Y INDICATED AS DRANN �
FROY INFORIIA ON F D IN BOOK __C__. PAGE '.
"a CARQ � C__: T1uT T R 0 OF PRECISION AS LAL-
'�'� ••����'•. CUTATED IS 1:__ _00�__; TNAT THiS PLAT FAS
;• P : .... .
•;20; 4F,5$/�••;�'y i: pREPARED IN AC ANCE �ITH C.S. �7-30 AS .
��O 9•� : AUENDED. NIT 5 ORIGIN�I SIGIUTURE, i
r� ' RECISTFATI MWBE AND $EAL TNIS _� _ DAY j
: 4 L-2465 � oF
: a%'�O SUiN�.C`,;::
'�q� •C HA�'�' StH
....... os
r+uyeert --------4=Ti¢5--------
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�x Ma� j ' �rc I R �
Suibd�ivi ian
h�.se:Sectian: �t � �►
��r�t 4Talid �or
Type of Facility: �
# of Occupants 'C
Proposed Wastewater
Proposed Repair: �
Permit Conditions:
T�pra�e�en� �'e�mi�
�sve eaa-� i�l�o �iHa�ion
3 � . New � Addition . . '1��ter Saa�p$y ���
of Bedrooms L. ojecteri Daily Flow 3�� g.p.d. �
System: GZC � � ' � Type:
� � • Type: ..... .
Ownez or Legal Representative
Authorized State Agent:
Date:
The issuanca of this permit liy � Health DeparGme� in does not guarantee tfie issuancs of other permits. Tf is the respons�ility of the
applicantfgroperty owner to in s�e that aIl Persnn. County Pla�ing and Zo�g and Bui7ding ?nspeitions requnrements aze me#. Tlaas
�anprovement Persnit is snbject ta revocation if the si�e pian;�plat�'�'the intended use changes. '�he �soveaiemt �ernm�t is �m#
a�i'eett�sl bg� a c�a�ge in o�er"ship of the propertgT. T�is permit �aas issued in complianee �vith ttae pravisaom�s of the North Carolima, .
`ZBws arad Rules fOr Sewa�e ?'re�rineni arid IDisvosal Svstems' {�5A NCAC 1�A .1900). Pleither �'srson �Cmuniy:nor':tpr,e.�`'�
�nvir�nmental �ealth Specialist warrants that tbe septic tank systeffi wi71 contiiaaue to fnn�on satisf�cto�-ily iri tiae futnre'or:t��t�
th�wat�r supgnly will remain potabie. �• •
- ��atho�ation to C�nst�uet �astevqater 5yste� (k8�c�.e� f�r �aaa�d.i�ag Pea-�mii) � •
*.SeE site plan and additional attachments %)• �2 ��vw � � � . -.
. � � ' • pr • -
Progosea wascewa.ter System:,�� � C�mbe Ty-pe 6� �Iastewa.ter F1ow 36�.p.d.
New 'i R.epair_ E�ansion � ,� SQa� LT�B: . 22 � g.p.dJ ft 2
Type of Facility: 3%�� �QS: � Basement _ Yes _ No .
�
'��te�a�er Syst�� Req�ag�re�a��a�s
'�� Size: 5eptic'T�nis:' � o�gal �np Taatic: �B� gal �Gresse Ta�p: �- g�l
%Zc90 �� f� ' I4����a Trenc� �De �9n / � `Ow ".5���
I�rrainfe�d: Ta� A.r�: sq ft Total Length P�_ �iw+1 S�
�r.�ac�a'4i�idtit � f# 14��a�a Soi� �ov�r: rP in � �effi�n �ep�tona ( �it
ID�st�ril�u#ion: �3is�daibuiaon �oz Seri�l �'�tribn�noa � �res�e �fold ' . .
Sp�$'ications:
�m�9a��ed State Agen#:
Permit Ex��
The type of system permiite� is
Pesmi,t• �
��e�Ll�ag�l �a�rQ��ssia�ive:
�
Date:
Date:
I a�:.�pt the spe�ifications of the
Date: l2�2��/1
PCHD rev. l 111010�._ :
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SITE PLAN
N� � �a '"� Ta$ Map #� P cel #�
Subdi ' "o Section/Lot# �
Authosized State Ageat Dat ' '
System compoaeaismpreseatapproaimate conmurs aalp. T3e coauacmrmustBag� the systempoor m be$iaaiag tfie installarioa ta
l..o,,.,. thatpmpergnde is mamrrraed
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424.09
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Tax Map: �
Subdivision:
WELL PERMIT (New � Repair�
Parcel• �
Lot: g
Applicant's Name: ��i i �P R �/ 'Ta �
Mailing Address:
Phone Numbers:
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.
Other Co�cditions/Comments: �p2�— -�i►,� p2r,�, `� �
Permit issued by: � ''��/ Date: � 2 �
CERTIFICATE OF. COMPLETION
New Well Inspection:
� EHS/Date
Location:
Grouting:
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller•
Pump Installer:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Liner Inspectionr
EHS/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Completed:
Method/Material(s): _
License #:
License#:
Date:
Date Results Mailed:
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
���, � �'I��.���
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���� �¢� ���,�� Owner. �
Tax Map: Parcel #: Date: z
I.ine Tap Tap (Sc�) TaQ �'lopv Line Leaagth �odv 1 foot
# iiiameter(in) ( m) � : � ft)
1 � z i�o < a , o� Fr
2 �
3
4
5
6
7
8
9
10 �
�D ft of line x 65 er 100 ft =`Zfocr� �'-'? ; 100 =� o gal
75°Io x 2Cto ga1= � gal per dose 3 gal per minute (gpm) = k'lo�v I�ate
Friction �ead
I.oss: Z• 3 ft per 100 ft of supply line x'�" �� v ft of supply.line ; 100 =-2 3� ft
Q< 3 ft x 1.2 ='3 �� ft of friction head
Manifold Size: �" Force Main Size: Z" PVC
TotaI D y namic �iead = 1�ft of Elevadon head +_� ft of Pressure head +�ft of
Friction Head = �_TDH
Pump Requirement: 3� GPM @ 2 �• ft of Head
Drawdown: �_�al per dose : 21 gal per inch =�_ inch drawdown per dose
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IdEMA 4X Simplex Contml Panel
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4" X 4" Pressure Treated Post �
� Sloped To Shed Water 12" Separation
� Elzctrical Con�iit --
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6" Cover • ' � Access Cover • , ' . ' . � 1 �'
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. , o , � �` _ - �^, � ` .
. �., Opening Filled With . �nti Siphon Hole \
Inlet F:nm Septic Tank Poztland Cement Cnvut (Donm Hill)
4" SCH 40 PVC Pipe � ' •
Check
, Valve
High Water Alarm Level
� (6" Separation�
. Hish Level - Pvmp On ---r�
� � � �� fiVapor Lock
• � Hole _
• .; DrawdDwxt �Up Hill)
. . Law Level -Pump Ofi ---�-�'
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T�x M.� � � P�rcel #
� uhclivisioii
Ph,�se.'S ct�ion tot # ►
Duct SealBoth
Ends Of The Con�ii4
� 24" Miiunnun •
:. ., .-•, •. , ,
Threadzd Gate Valve •
;. _ _ _ . ,....! _
Zip Co:d
Ties �
Nylon
Rnpe
Concrete Riser
b" Separation
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'Y:,r.--Porllaxul Concrete Grout
. . • Mastu - • - .
. � Openuig Filled With
Supply � ' portland Cement Grout
Line ••
Outlet To D'utnbuiion
2" SCH40PVC Pipe
Float Wues •� �
•r
�ats t..
_R.emovable , ; .
F7oat Trea , ,
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' Pzecut Concrete Tanlc 4" Concrete I-�}-
� • � ;.; (MaterialStrength>3500PSI) Block � i
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