A24 9A� 2 4�0 �
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0
�y ��Ob 3 �t�- 5l t� - Otpqq
I
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(� _( � �, �� /�Le`��tt/.
�
�
�
,�..�w �,� �u,. �:� Y: s
Application Date: �- 22.-�q Q� •�,�-� �l��a�\
Amount Paid: 20 o a�'- og0 Q Q�c��
Receipt#: •�c����
�-���_S� ������
' -� � � �� °1� �
�������r�m,.��,�zc:.�.n 1��.t,..n�:�.
Application for Services
(Septic Systems and Wells)
Services Reauested
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit required)
❑ Well Permit (New/Replacement)
$225.00/$125.00
Tax Map: �_
Parcel #: �_
� Construction Authorization
(Fee is dependent on the type of sys
� Permit Revisiou
� $75.00
❑ Repair of Existing Septic System
No Char�e
Important: If the information in the application for an Improvement Permit is incorrect, fals�ed, or tl:e site is a[tered, then the
ImprovementPermit and tfieAut/iorization to Construct sl:all become invalid
1) Services Requested by:
Name: tJ E�L G. 1-� P� ��T-r Phone #(home): S 1-`-'t -��¢ 2 o Fr-
Address: j�a t3o�G tZ� � (work/cell): 59 7- pgo ¢- cc!/.
20 )C,L3arav , h1C � 75?3
2)Name and address of current owner (if different than applicant):
Name: � o�L� SNYDc 2
Address: p o C3 v x ¢ S S
}-il L�-56a2oUGt-t � N L, 2�'1 Z��
3) Property Description: Lot Size: S, � 1 Subdivision: N l/t Lot #: �.1�,4
Address and/or directions to Property: Se ��T-i-A c+t �� G'2 s Mq !�s
4) Proposed Use and Type of Structure:
Residential k Business/Type: Other
Number of bedrooms 3-�f- / Number of people served (seats/employees):
Basement: Yes No �(with plumbing: Yes No _�
Garbage disposal: Yes X No
5) Water Supply:
Private Well � (Proposed Existing _)
Community Well: Public Water System:
—�tIiere on the adjoining properties? No Yes
(please show location on site plan)
Note: A completed annlication must also include:
➢ A plat/site plan of the property that shows property dimensions and the size and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form verifying that the property is ready to be evaluatec�
I am submitting this application to request services from the Person County Health Department. The
information provided is accurate. I understand that if any site is altered or the intended use changes, all
permits shall become invalid.
Signature (Owner/Lega1 Representative): IV.Q� C � -t-t , Date : i - �Q -O �
06/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
FLAG
LINE # COLOR
TBM
INSTR. 1
1 BLUE
2 PINK
3 WHITE
4 YELLOW
5 BLUE
fi PINK
7 YELLOW
g WHITE
9 ORANGE
BS ft
4.0
SHORE ACRES LOT
Project No. 7491.S2
FLAGGED DESIGN
HI (ft) FS ft ELEVATION (ft) LINE LENGTH (ft) LINE LENGTH (ft)
100.00
104.00
3.40 100.60 50 50
3.40 100.60 81 80
3.40 100.60 36 35
3.90 100.10 92 90
4.80 99.20 80 80
5.40 98.60 80 80
5.80 98.20 80 60
6.90 97.10 60 60
7.90 96.10 40 40
Totai 579 575
DESIGN SOIL DESIGN
LINE LTAR SYSTEM LTAR DISTRIBUTION DISTRIBUTION
LENGTH (ft) GPDlFTZ TYPE GPDIFTZ MEDIA METHOD DESIGN FLOW (GPD)
System 275 0.30 Innovative 0.30 EZ-Flow Pressure Manifold 360
Repair 300 0.30 Innovative 0.30 EZ-Fiow Pressure Manifold 360
Notes ** TBM AT BASE OF FLAGGED TREE
**TBM is assumed to be 100'.
**All measures in feet.
""Nitrification lines are demonstrated on contour via colored pin flags.
**BS, FS indicate rod readings.
����, �� I�1� ; ���
. ������
�t :na s�a Kaa�.��,e.�.0 ��.�,� O �er:
� . Tak iYlap: � � Parcei #: Date: 5 =ZSI -�9
I,�rne '�a� '�ap (Sc�) Ta� �ow Liaae I.e�gt� �7ow / �oo$
# I�iaa�ae�er(ian) ( m) (ft)
$ t � : go 5.5 D , �
z
3 � �
4 �
5 D .
6 �
7 ' �
� � �
9�
10 2$'� 2=
�Q_ ft of line x 65 gal. er 100 ft= ' 100 =� gal
75% x gal =% 1� g� �er ciose �? 30 gaI per minnte (gpm) _�ow �8a�e
�'rictivn I�e�ri - � .
L�ss: r�-�ft per 100 ft of supply line x� ft of.supply ]ine = 100 = �i ,� ft
. ft x l.2 =�_ ft of frictiorr head . �
Nianifold Sez�: �-'t' „ �'orc� �Iain Si�e: � "PVC.. .
'Total IDynatanac �ead =� 3n ft of Elevation head +�_ft of Pressure head +�ft of
Friction Eiead = �_TDH � .
�ump 18equire�nen#: 3a .. GPM @�C(_, ft of Head. .
I�t-awdown: Z15��,�a1 per dose ,-` 2l gal per inch =_ rf �� inch drawdown per dose ������d�
esfi��
�ea�fl.I9� Inf��s��
� .. . . . , .
gvcr� v� �� T� "�'��� � �' � � —�
��. pFANV]EW rvcr�. vffiw
�' .�-- �, o 0 0 0
��� � ' '
.
���'"� r:avsr.l sTnetEHasa
��
�ia� � .
.+,;.�+ , ", .�"'�` • . i4ianifold Size / � Ta s
�, ��,,.,,,.,.,.,.�.,. .ti �l�Ianifold Maz No. Taps off one sidc
csm. (ite�uce b� Il2 for tappin� both
�» � �
���i� �
�� � gm�r
^,.+.4-,-».-�: ,.ti-�.,•.�-.-,., �
�
V �.wti•�-r+�+•i�+�+• •�•ti •�
i.+.r-r.x�r.�.r w-.a-+.i-rw �
a�� .
�
1
4 � �
9 5 3
16 9 '
�D+ 21 12
.. � Flow per TaP -
Si.2 iLlarerial FToti�� iu' �il
,.,• Sc.yed <40 �.�
;. " Sc}red 4U i.l
�/, " Sched 80 I Q. ! I
,%, .. ! Sclied 40 1=•= 5
������� ������.
`'.� `' � J �-,_„ � � � � � 11
I���.�-a�-���«����.7L 7�--�����Il�.
NEPviA .4� Siznglex Coniml Panel
�" ;� +4" Pressure Treated
Slopad Ta Sl�ed Water 12° Sapsration
� Elaetrieal Cobdni.t �
' :,, • �A .
. . ., . . � . .
• 6° Covar •� � � Acc�s Cover• ' , ' : ; 1_� , i
� . , t _ '' , i
. '. ' i � .
, I i j �� • �' . i
�, i,. OFening Filled Witk� . Anti Siphon Hola' �
Iz►1et Fmrn Septia Tan]c Portland Cement GxDut �p� g�1)
n
4" SCH 4Q PVC Pipa � ' ' Check
' ' . � Vai,ne
- �iigh ih�ater Alarnt Level
,'. , (b" Sepazation) .
: .. �., . x3�h Le,�1-1�r on --"�.,.
• ' ; rVaporLock
� � �- �
, . �� � _�_Draxdnpm �Up H�11).
•` �
� , Low L�Y�al -F�ump Ofi -�-'~'
�'' .
� •• ti
' Precsst Conr_ret� Taalc
i� '.; &YaiesialSir� h}350Q
/
T�x Ni.a,�� : P�:reE�l # �
5.ti�h c6i v1 s i�o n
PI�����;�e:5c�c.t�ion.'L.ot �
Uuct SealBoth
Ends Of The Coxc�it
�- Z4" Miniaxc�m --4
�.•� •,
'�;ht�adad ��e Yalvs
Zip Gv
Ties
4" Corcxeie
CpYlC2L°i8 R]S@Y
&" Sepaxation
��.-Po'rxtland Cox�ret� C`smut •
_ ;� 14iastic • - ' .
:� . .
:•' ,�Y�• � �
� Opeziing Fillad With
Snpply � :.' poxtlsnd Cament Graut •
Lina ° • '
4utlet To Distttbution
2" SCH40PVC Pipa
' F7ast Wir�s �' �
. :. •
t� r
�7aats . ;
¢ltamovabin '��.
Fioat Tsaa , ,
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II ` '�. ; . . • ' • . s .r � , •� _ • � �� ' 1 1 , ' •.
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; . . � .
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I�u�v� �►��
n
3v � Pl� � ��' � h�
�c E(Pva`�'oh iS
es�ima,�
WELL CONSTRIICTION RECORD
Ttusfonacanbeuud f�smgicorm�Japi��s
�. wdt coA��� �ro�so� �
G�o�v,�J i e �, �R c�� �7`
w�uco�N�
3� 6 �
xc w� co�c�s�oA K�
Barnette Wetl Drilling, tnc.
Car�anY Name
L�Vdl Conshvetion Permii #: .� �� y�� �t�
(�ct all opplliwWe urfl corua�ala+l�er�nFa f� �+�Y
3. Ndl Us� (chectt wcR ase):
❑��� OMuniapaUPublic-
nGeoth«znat(HeacinslCoolinssw�v�r) ox�siacntiaatwatasnpalyising►�)
QIndustriat/Commacial ORcvduiaai WaterSupPh'(�
���R�y�� DG[OnndwelerItert�Cdlatial
QAqnifa Smcage and Ra�v�� OSatiaity Basriv
Ra
QAquifer�est OStona�raoerikainage
pEspmai4a�_ITalu�ology DS1�sidrnceConttoL
QGm�sa�i (ao� LooP) �T�
4. DatE�
5a We11
compi�c�S'/Z- w��iwu /y 2 �i'�
�
n�
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. . _ � A.
��.�.�,a� �/�
�� � so�
�a � e�araaa;�Nac�
Sh.Ist
(ifwa9 i
�
6.Tt (a�
7 L th
,�dds ts
�•
&Nua
Faram
�u
9 Tot
I�ram
�Q S�
�ff�
iL&
12W
tix.w
FOR
i�.'
13fr. �
�
Forintaml Use OM.Y:
� �. c�p a- f3 (
2 Zp� 2 �o � 2sr/
�5.UIFTERC�'�G(f� � D��-�rrdlc
FROM 't'�
t� 6 z �- G � �-
1&�INNEK GASIHG URTOBIN�G��
F1toM To
. tc � �'
:� � �
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tou'r. - �: �
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fo sh�—/� A
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deaad Lo�dein d�luitunteslsaooaarar decimat deEr� 2Z CatiS��
����� �v � �% S/Z �l7
� �� � 6.��N � � . Q E'� � �� 4V �G^Y�>'��.J.��{.l�t�-� y�-- �r / Dnc
��yq� R�W11����
� Ql�em��` BYYs�d�tfarsRliaib!'ae+�'�tbcx�s,iroi:�e++��lnaaacsdo+ex_
the�(tk GP�� �{dr1581�IGtCQaCAl00crISdN�[CO�C.OIOO�sQCo�nrWo�Soa�ar�aadthata
`� �'q/t�„erordiorauu�ro.tdad ro tbe xeU orua:
i tejwir w aa �tingweib OYes oe �3Pto
q��rjdlaat�r+vwtr�eAQoe�a�o�+����p0°�Ol�°` Z3.S'itedisgcamaad��defait�
rt2i moartsmdon ora� d�cLautQl�I� You amY ux d►e bedc of 4iis pa8e to Pzo°'de a8ditiawl vsll ste det�'!s or wdi
a
' ! �i�ddails. YoaaiapaLtioaromd�addiriooalPagcsif�Y-
r oiwdls constrad�d=
ep�nTvaarnoaanerarq+P7Yre4sONLT�dbtbesmxaa�me�.S'�+� S�b�ALiN.S1i1CliONS
� A6 R+e� ��s iotm w�a► 30 days � oompldion of v�r11
v$► dePtb bdow tand mrfae� .�O C� (tt) ��---- .
ereuslt:ra¢dq�sif�f�►�`��'°°d�� ��iflx'fallamii�
Dirisioa oiWateeQm�+t�.�°o' ProoessinEUei4
;waLr�'le�d6ebw�opofas� � ��� 1617Ma�1Sa�a�•���2�9-1617
et lsatw•so� ssr -+- du fwm to We addtess ia 24a
wle dtame�er: (un.) Z4b�. For Iaiadae We� Ta �dd�ion to sead'ui8 �Il
���� copy of di� fmm wiiliin 30 da�s ��uP� �.
�i�2.�D��'62�/ �mt�etouaaem�
rnnsh�aetion method: ,_ Ceaaroti Pra�ram.
�+�7. � d�.ea p� �1 ��ate; Qs�Y� II��d I�tla6m
163iMa�1 Saviee CeataraRa�+� 27�9-1i36
�TCsR SUPPLY �LIS ONLY.
BIOtNnZOliii ?AcForlVaterS�motv6einie�:�Wdlz ����� 30 � of
3 MetLed of t� - tha sdd�ess(es) �o+� dso m6mie oa coPY
la c�) ud of shc canay
iutccsontm� HTH p�� 112 CuP �� �O° m dx oo�ty ��
m
rr«d� c�� � � ma r� ��-� �w.� �r
��'—" G .•-ti-.. . _ ....�.-- _._....__..___. -----. .__.._.�—�—�— -------------•' -_ .. .
;r ���� ��� �!� : �� .l�C7 �u..f" 'i� .�
.�.r ��:�������
I�',.�:3�� :� ��-:� � �.�.�.Il IF-iC � �.1�I�.
�/'b%��,� �L{ ��/i�.:L� �''��°JY 1/ i'���:3Il&'�
�'��Z i���9: Z1 ��5'���:
�iIl�D(�i�Il3n0E&:
�-���a�ncaa��'s �1��ae: I� �• er
I��ai��n� Ad�r�ss: � , �5S
"� S ro 1 Z
�'�on� t�aaaa�a�e�:
�.,at:
T,1 See attached siie plan for p�oposed well Zocation.
Z) All crpplicable State and County reb lations governing construction and setbacks a�ply.�
3� Permits expire � years fYom the date of issue.
�t3eer C'r��adi�vn5/�'�nas�aen��: � / , ,, �,�
,
���r�n� as�a�ed ��. �a���: S 2$'OQ
��1�'����a�'�'� ��' ��1����'�'���T
1��� ��� ��n�g����n�an:
HS/Date
Location: � ( �-��
Grouting: � 5���
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
���1 �r�le�• �j4r�.Qa}�-'�-
Pump Installer:
����� r�ppr��e� �w:
Date Samp1_e Collected:
°erson Counry Environmental Health
_2� 5. YlorQan St., Suite C
Ro�boro. NC �75 i�
�..,���� �s�������n:
EHS/Date
Installer:
Depth:
Grout:
�1��� �������n�aae��t:
EHS/Date
�ompleted:
Methcd/Nlaterial(s): _
�as���� #:
i icense#:
�ate:
Date Results ltiiailed:
�hone: 3�6-�97-1790 : �.�: _�0-�97-7803
8/1/0�
��� � �. ��� � ��� �� Tax Map � F�rcel # �:
� ��) � � � � 5u�bd'ivision
� �� �� , � � � �� Phase Sect�ion Lot #
Permit Valid for
Type of Facility: .
# of Occupants L1f
Proposed Wastew
Proposed Repair:
t Conditions:
Owner or Legal Repres�
Authorized State Agent
Y
#ofB
Improvement Permit
No Espiration
� New Addition
s Projected Daily Flow �$ D g.p.
Water Supply ��
Type: �.��
Type: �'q
The issuance of this pernut by the Health Department in does not guarantee the issuance of other pernuts. 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 Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not
affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina
`Laws and Rules for SewaQe Treatment and Disposal Svstems' (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 (_J.
Proposed astewater System: /�cr � w/ o�,,,tx� �Ez-�foWor �k���Typ� Wastewater Flow_�$�g.p.d.
New Repair_ Expansi n Soil LT ..�17 g.p.d./ ft 2
Type of Facility: �; �aiZ e��C � Basement Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: 0 O gal Pump Tank:, �F��� gal Grease Trap: — gal
Drainfield: Total Area: �,i sq ft Total Length �'��� ft iVlaximum Trench Depth �� in
0. C,
Trench Width �_ ft Minimum Soil Cover: �_ in Min' um Trench Separation: � ft
Distribution: Distribution Box Serial Distribution v Pressure Manifold �
<<
Specifications: �
Authorized State Agent:
Permit Exn:
`�i
Date: �'ZS' U� -
•�
, �
The type of system permitted is Conventional Accepted W��Alternative. I accept the specifications of the
permit. � �
Owner/Legal Representative: /�� � ate: � �
PCHD rev. 11/10%OS
� ' .�� 1�1,J� ��/'�'� �'��.�� � �
�� � '�` � V � �L .11..
]E �-� y- � ��.a �.�.11 IE3L � � �.
. �ITE �1 TCH � . . �
Na�ne r��� d er Ta.z Map #�_.Par.�el � qf�-
. �-� .
Suh on . Section/Lot#
� �--2�s-�,-q
. Authorized State Agent . � Date .
Syrtem cvmponents �.presesit uppmximate�contours o�ly; The coniractor must. fTag the syste»,�rior to ;
beginnimg the in.rtalXation to insure that j�ropergrnrde is m.urntained
.._L-_ �� i�l� a � � � s'�rn
— �d��p�cl ,� 7 Did�
�� (
— `��To � � �'`�� Pu'� 1
��
' J � `` �-ren��� 6�ms
�{ :��uy �� q D ,
'� � � g +
D
M.SS � St�90N
__
_- o , ____-
- os «
' + 3.LO,Z�.SoS ��
5'�}�:1"=100 �— ovoa 3ivniaa _o� �Kiisix3 �_ _ _
_ __ _�
� �
NORTH
�Ur��2 ►�us� 1��2
j rc��-q �� q S S1Zc9wn.
Nla�,,-�a�'n af(
S�P�'bQC(�5
�
1
���.sf ���.���
�^ � � ����
I���na-�������.Il u33L��►.Il�I�
Applicant: ,l-��/�/��2
Location:
Operation Permit
Tax Map � Parcel # ��
Subdivision �/ ,�� /��� ,
Phase/Section/Lot #
# of Bedrooms
System Type (From Table Va): Product (IIIg): ��,�, �
Type V& VI Expiration Date: Type V& VI Renewal Date: �
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.
�cal� �
PCHD, rev
� .
(Q-?�-�7
( uthorized Agent) (Date)
c�-2�-r�
icensed Contractor) � F � s.d (Date)
--- �- o
1� 3�3
�✓' t-�a.� �— i c00 �JI i z/3%G
�8 760 �o,
3/zy/r! �n�s�
,
waii _ _
� �
�� ��;,r.,....--�-�'�.,�,,.�s�,,.s..,�.�
�
4iia '�' �' ° ..� �,d (��b
3�--�. �'''S��� (o 0
��� ������
�/�6/�7 ,�tv
� w��
Tax Map: `� P�reel #: �.�
Septic Tank System Checklist (Type II-I� System Type: _��Z�
Notes:
Pump System Checklist
Contracted Gertified Operator (Type IV Systems):
Notes•