A24A 18Apalication Date. ��`���,`'�
Amount Paid: �SU•�
Receipt #: �3YS3 __
�� �-�53
.�;✓'t.n..'"J I�iz (.-acw�-lv� ���G �.�
� . ��ti ��
Tax Maa #: � Z C/� n-/G� I 7� (�
Parcel #•
.
�`������ ������
' —ti- � � �LJl� � �Y
���a-��,--.--.. m�.�.�.n: ��.m,a��.
APPLICATION FOR SERVICES . '
IF THE IIdFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT 1S INCORRECT, FALSIFIED,
CHANGED OR THE SITE IS ALTERED. THEN THE IMPROVEMENT_PERMIT AND AUTHORIZATION TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Ownedagent/prospective owner): )«:.c.�. W Ps +� W fs ��oNs f•-� c r�
F Home Phane: l�33G: t34-y z tD Address: l trv 2 i µ��, /��,: „ k r �2c•
� Business Phone: � �i'3 �1 �7 �o -� �c 3� S��u« �.. �svc 2 �? u3
2) iVame and address of current ownen C'� s c:� r 5 G�, c, �, -, o�
3j Property Description: Lot size: Township: Subdivision: ��G,R.: � Lot #/G� /�� `�
Directions to the property (Including road names and numbers):
�-�' ov� Z iUv� �e..cl C%ur�n IL� L� �-}- nn 9�tn�c rio[ivE� /L�
4) Proposed Use and Structure Description: answer each of the following questions:
a) Proposed _, Existing ,� Type of Structure:5�/3�r.+�• /�:.� L Width: �� Depth: �a
' b) Number df Bedrooms: _/� Number of occupants or people to be served: �_
c) Basement: Yes�No _ Will there be plumbing in the basement?✓
d) 6arbage Disposal: Yes � No J
5) Water Supply Type: Private ;/ (new _ or existing,�, Public_, Community_, Spring _
Are any wells on adjoining property? Yes ✓No _ If yes, please indicate approximate location on the
'site plan. �
? yw � t,,,.G �,�
6) Does your property contain previously identified jurisdictional wetlands? Yes � No_ I�.��u,
. � �_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT �F THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION.
➢. PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED.. ,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAFCED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEAIT
STAFF: �
I hereby make application to the Person_County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall
become invalid. " ,
�--
Owner or Legal Representative
2 '/s'-G 7
Date
PCHD, rev. 06/27/02
%J� G v � �ct�
Gv�v�Z��
1 ��
l �� _ �7�
+ 1�
.� �,
-`'�*� The Disfricf 1-le�ith Depar�ment .
�� � '`� Oraage, Person, Caswell,•Chatham, Lee Counties
. � ��tli i �r� '
` � ¢ �'` �� �� SEPTIC T�►NK PERMIT
w a� , , .
� � a� + .
Hn � ' •.r ...
� Dat �� �
_ .. ' �y `d � � ' :� �"�� '
, . �,� : �o�y �, . Name of owner: <
� ,� ' _ ' 47� : • Q O . ' V
` � � ` • ax � � Name of contractor: � �%
r' , � d � � �
o, ��� - Address and Directi�ns - p
; k •A �.r � � fl Aj
- ; A . � . 3 .�3 `►I r�=.
. } � . .>, , : � -
. � o' � • Person or firm doing installation: � ' " �
, ` C 4/?. i iidC�TCSS ��—�7 f�------�d�, �� � ��"f�� I�/ �f _
, .�
p �T'
-• � � �' No. of persons to be serverL Bedrooms 1, 2�3, 4.
�' �
� Additional appllances to be used: Disposal, dishwasher, washing :
~ ����
0
� � , �° � machine �
: •.. ' � � p ,.i " co �+ � .� .
� �� �Recommended• Septic ta /
;; ," t .� : �, o . .
i . � � , o � ��9
' ,. � , � � � : • Nitriiication line: � � •�,� "�'
,�.• � ti �
y �" Above recommendation based on information received and observed
' � w c`�o � � soil condition. Septic tank and nitriflcation line musf be inspected and
. o ��, ',' approved bp a member of the District Health Department sfaff before
any portion of the installation is covered.
� x `' �
.� V� �
. wtl ,
M°' o � Date Approved: �� e�.r ��
. i � - � � ' •',
- I� ' _ ':� � � ►�" 1 .Slg'II2cj j ;
. � � �: � Sanitarian � �
,.;
� �n By. , . .
i . - � * �' , :` ; � o�i , . , ' O. David Garvin, M.D., M.P.H. �
� y . District Health Offlcer
m � •
� � � Countersigned
�.
(Over)
�,,. � �+ -
�
. H r�% . . . � � .
��� •
Anplication Date: % �'� 7
Amount Pald: �
Recei t : —
C�'-�
��� �
?-�;
.: 'r'
;s/
Tax Map #: ��l4 l�
Parcel #:
rcco,z.P ,# /(�3 �
����; �� ���.:� �� /l 3�
— —�-- � �`a�'�'� � ��33
�scavaa-�aa-R-*-� .oaa�mll g—�omIL�E7�i
� APPLICATION FOR 3ERVICES � �
IF THE IfdFORMATIOIV IN THE APPLICATION FOR AN IIIAPROVEMENT PERMIT IS INCORRECT. FALSIFIED.
CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATIOId TO
CONSTRUCT SHALL BECOME INVALID. -
1) Permit requested by: (Owner/agent/prospective owner): ���� ` e��
� Home Phone: 33l � 13�1- Ra� p Address: 1 i
Business Phone: _ Sa. H.,� �S�S,�rr.�_. .vG a-> 3�3
2) Name and address of current owner. /' cz.^
� .
� _
�
3) Property Descriptic
Directions to the pra
_ . . , _ ���
4) P�roposed Use and Structure Description: answer each o the foll wing uy e�tion��
a) Proposed _, Existing x, Type of Structure: �a i t: Depth:� �
b) Number df Bedrooms: �� .�� Number of occupants or peopie to be s rved: .� ��
c) Basement: Yes� No _ Wiil t re be plumbing ig�e�asement? ,
d) 6arbage Disposal: Yes � , No �a�t v� ad' G,,trrer.t �tJ. S�vs1 D/` �� n�� a�L
� /18L'a�C� �
5) Water Supply Type: Private �( (new _ or existing , Public_, Community , Spring _ �
Are any wells on adjoining property? Yes No _ If yes, please indicate approximate location on the
'site plan. . �
6) Does your property contain previously identified jurisdlctional wetlands? Yes_ No,�
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICA'iION. .
➢ PROPERTY LlNES AND CORNERS MUST BE CLEARLY MARKED. •,
➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAICED OR FLAGGED.
➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMEAIT
STAFF: �
I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this application are true and represent the maximum
facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shali
or Legal Representative
� �
D te
PCHD, rev. 06I27102
` a .
� ���� I' � � � J.3.L7 � 4� �1 � �. .
�.�.-. � y ' '� �T
I �� � � �lrJ � � �
1��.-���„-„ �.-�-� <e��.�.11 I�3L��.11�1�.
T�x Ma�� � � �rcel � ;
Su�bd�ivision � � �, . �
Phas�e,Sectian.'Lo�t �
P�r�t Valid for�
Type of Facility:
# of Oc�upants �(
Proposed Wastewater
Proposezl Re�air: _
Conditions:
r �
j . i�pravemen� �ermit ,
��'ive 'Ye� l�To �ira9ion j
, �� K�r�ev�P. .1vew ` Addition
Q# of B�sirooms ��_ Projected Daily Flow �
L �.
V6�ater Snpp�y �
g.p.d.
Type:
'I�pe: �
Owner ar Legal Representa ' i e: , � Date:
Authorized State Agea • � Date• '7-- Q- h� ....
The issuance of this pemnit by the Health Department in does nnt guaraniee the i���s of other permits. If is the xesponsibility of the
�li�P�P�Y oamer m in sure that all Peison Coimiy Planaing and Zoning and Bu�mg InsPections requsemenis are met. This
Tmprovement Permit 9s snbject to revocatlon if ttie site plan;�plat'`or�the intended use ciianges. The Impravement Permit is not
a�ected by a change in owner"ship of the property. This permit was issued in compliance with the provisions of the North Carolina, .. �
`Laws and Rules for Sewage Trermnent and Disnosal Svstems' (�.SA NCAC 18A .1900). Nefther Person �ountty.: nor�"tiie.` "� �
Environmental Health Specialist warrants that the septic tank �ystem w�71 continue to fnnciion saiisfactorily iri the fntnre�or:t&at.
the-water snpPly will remain potable. __ . ,
• Authoriz�tion to Constrnct �astew�ter Spstem (Requared for Bmlding Permit) �
* See .rite plan and additional attachments (_). . � � .
. % .
PropoSed astewater System: L� �(. J d;�l d r G��'ge � Wastewater Flow 3�n �•p•d. -
New � Repair ExQ .� Soil LT 2 g.p.d1 ft 2
Type of Fac�ity: .Pf i vdi� i P' � � Basement es _ No .
�astewate� Syste� Req�rements
Tank Size: Septic'�ank:' iODb g� pump Tanic DOD gai Grease Txap: —'�� gal .
Drainfieid: Total Area: �Q_ sq ft Total Lenigth �� ft ' N�mnffi Trench Depth / 2 in
O�G.
Trench Width � ft lYlGni�nm Soi� iover. � in �'Y'rench Separation: �_ �t
�' ' ntion I)ist�ribution �oa Serial Distribntion ��e.gsnre Manifold .
�b
Specifications:
.�ntiaorized State Agen�
Permit Exp
Date- �-q-o7
The type of system perinitted is Conventional v Acc�ted �` P�p,�ternative. I acc�t the specifications af the
P��- �
i�v�e�l��al �apa��s�a�tatave: Date:
• PC� rey. l l/10/O5.-
, . .. . .
, � ..
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�.�-� �'' � � � � � �
I��-.rau-�����.�.�.]L R 33I�.�.Il�I�
NEMA 4X Simplsx Contml Panel
4" X 4° Pnssara Treated
Slaped To Sbed Watar 12' Sep�ration
\ Electrical Cow�uit ;
��
i
• , o
. . � •. .r • ' •' • . �
b° Cowr •� ' � Accet� Covar• , , • , ' : ; � .1 . ;
� . , „ , • 1
. ,i. , ,� ` r� ��' . �., � r �
� e . Filkd Wit� �
' i,. OP � . Anti Siphon Hok' �
Iztlat Fmm Soptic Taxilc Po:tWid Cement Gxout �� g�
4" SCH �0 PVC Pipe � ' ' C��
T,ux M��r�� ; � f'��rc��.l # '
Su,laclivi�sioi�� , - •,,,, , �
Pl���itie Sc�ct�ini� L�t i4
Duct Saal Hoth
En� Of Tha Con�iit
-'� Z4" Miaiznum —i
'' '� - - -
T��a� � v�,�
Zip Cord
Tie� t
. •t,
' • Valve 1
• High Water Alaxm Lavel
. , (b" Sepuation�
�: ,_, Hish Lawl- Runp On
' ' : ,� �VapoY Lock
• '.
. ' $ole •
. . � � Dravrdvwn �Up �� i
, j
Law Lavel-Pump Ofi
. ,_ • . , . Pu:t
,..t
' P:ecaet Concrnt¢ Taak � 4" Concsrt
' •�;.; Matezial Stze h}3500 PSn E1oek
.�
� `...... • . ; ... • _ , .� . . , '�
Concreta R'ver
' � � �� �n Separatinx
�,,:,��Po,r�tlandConcreteG:out •
• _ ;; Mastu • - :
..� - � .
" ' . •�, - :
. � Op�x�ing Fillad With
Supply ' ' ' portland Cament Graut �
Lin.o � • ' .
Outkt To D'utn'buti,on
2" SCH40PVC Pip.
° ' P1oat Win� .' �
. ,: i
�Datf +; ,'
�xe�,►��. �. : �
F1oat T:as �.
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�� 00 b GALL�JI�T F[T1V8 TANI�
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3s �Pr� � 43`� ���.
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1[� ;na-s-nn-Kaana�ra�e�ra�E.m7L IHL�ern.Il,E1la Qwner: _
Tak Map: 2 � Parcel #: �4�
Date:
Line Tap Tap (Sch) Tap Flow Line Length Flow / foot
# Diameter(in) ( m) (ft)
i r ,� � v , pg .
2 , ,
3 � . �
4
5
6 �.5 0
� -
s �
9 �
10
�(� ft of line x 65 gal. per 100 ft = ;' 100 =��, gal
75% x gal =�� gal per dose �_ gal per minute (gpm) = Flow Rate
Friction Head - :_ �
Loss: 1.1g ft per 100 ft of supply line x�-28 ft of supply line =100 = ft
ft x 1.2 = 1�, '1 ft of friction head .
Ntanifold Size: �_� ". Force Main Size: 2"PVC �
Total D ynamic Head =�ft of Elevation head +_�ft of Pressure head +�ft of
Friction Head = �_TDH
Putnp Requirement: 3 S GPM @�3 . ft of Head.
Drawdown: ��gal per dose ,—.` 2l gal per inch =�. � inch drawdown per dose
��� �:. �� � � ��:9�,
' =,.. . .. �v �
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2" �n
Sc�ednle d0
PVC
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9 aams
� 2„
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6"
3ize / # Taps
No. Taps offone side
v �/: for Yapvin� both ;
�
E
.. . _ Flo� er Tuu -
Si:.e lllaterial FIo��� GPli�l
t/. " Sched 30 S•S
� ;." Sched4U 7.1
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3� .. Sched 40 1-. ;
.
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7��-o-ny-����m.�.11 ]HI���
� SITE SSETCH � .. . . .
Name ���i' r Taz Map #/�'Zy/�� Par_cel #�
Subdivision � ' o u �t:� , _ � Secti.on/Lot#
. - �`o�—
Autho�ized State A.gent . � Date .
System campo�ents �e�i�efent up�irna�ima�ta'contours only. The con�ractor must, fTag the system prior to
beginning the installaition ta is4sure thatpro�tisrgmde rs maintai�ed
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Tax Map �_ arcel # �� .. Tovvnship:
Applicant:
►5'il�](�1V1310I1: T nt ff
��pe of �ater�5upply: �/ 7ndividual _ Communi Public
tY
I�equiremeaats:
Site Approved By:
Grouting Approved By: �
Well Log. �
Pump Tag: .
Well Tag: ' �
Air Vent: � �
Hose Bib: �
� Casing I3eigh� �
Concrete Slab: : � � ' .
Well Driller:
Well Approved by:
�***See At�ac3aed �ite Ske#ch*�**
Liner:
'Installed by: _
Depth set: ,
Grouted:
Date;
Water Sample:
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions:
Date:.
PC�3D r�v 01.�27104