A24A 25- 0915
PERSON COUNTY HEALTH DEPARTMENT
WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT
Tax Map # � � � � � Parcel # • .� � r •
Zc�ning Township ` ' c
Owner/Contractor �' r,n .� p cx�r n�1� m �. �G I I te C1- �f - 9.�
T �noti�n/A��rncc �A.1 _._ r� �� l/l.ff- /2!L/ L� lYnn�i 0,.� 1-T{''..� �d� ��7 �
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SEWAGE SY5TEM SPECIFICATIOr
epair Lot Area�tPl'�°r' �c�c.f'� Size of T
FD Mobile Home Size of P
usiness # of Bedrooms_ %�_ Nitrif�
As Installed
Permit Void after 60 months. Permit Void if not in compliance with zoning regulations.
Permits may be voided if site is altered or m/�ended us�j change�d.
Well �t Layout by �n..�(/� �� /'�^11�y =-11-� S
Comments:
�� Date Installed by Approved by
�� C'_� G� _ rr�-r r
� Well Permit Paid WELL SYSTEM SPECIFICATIONS
H Individual�_Semi-Public Required Slab
Public Replacement Air Vent
Site Annroved �,S r�vr�fa/r► Required Well Log _
Well Head Approved Well Tag
Grouting Approved
Comments:
Date Installed by Approved by
This report is based in part on information provided the homeowner or his/her representative in the application submitted for this permit. The
environmental health specialist is not responsible for false or misleading informarion contained in the application. The environmental health
specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or
misleading statements provided to him in the application. 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. c:�amipro\permit.sam Ol/95 rev.1.0
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State of North Carolina
Department of Environment,
Health and Natural Resources
Division of Environmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
Mr. Jim Spoonermore
c/o Mary Margaret Hunter
550 Kelway Place
Winston-Salem, North Carolina
Dear Mr. Spoonermore:
4••
�
�EH N I�
February 6, 1996 U�� �,,,�h�
5.�.. `�► a��
Subject: Pernut Issuance/
Authorization to Construct
Permit No. NCG550804
Spoonermore Residence
Person County
In accordance with the application for discharge, the Division is forwarding
herewith the subject Certificate of Coverage to discharge under the subject state - NPDES
general permit. This permit is issued pursuant to the reGuirements of North Carolina
General Statute 143-215.1 and the Memorandum of Agreement between Nortti Cazolina
and the U.S. Environmental Protection Agency dated December 6, 1983.
If any parts, measurement frequencies or sampling requirements contained in this
permit are unacceptable to you, you have the right to request an individual permit by
submitting an individual permit application. Unless such a demand is made, this Certificate
of Coverage shall be final and binding.
A letter of request for an Authorization to Construct was received December 4,
1995 by the Division and final plans and specifications for the subject project have been
reviewed and found to be satisfactory. Authorization is hereby granted for the construction
of a 480 gpd wastewater treatment system consisting of a 1200 gallon septic tank, a
distribution box, two (2) primary sand filters measuring 210 sqaaze feet each, one (1)
secondary sand filter measuring 210 square feet, a tablet chlorir.atar, a chlorine contact tan;c
;�•:tr. a 30 minatc retention tirr,e, �ffluent �;���, and cas�ad� G�.aEi�,i witi� w�::..:::�c ui
treated wastewater into Hyco Lake, a Class B water in the Roanoke River Basin. In
addition, the system components must be located above the 100 year flood line on the
property.
This Certiiicate of Coverage shall be subject to revocation unless the wastewater
treatment facilities are constructed in accordance with the conditions and limitations
specified in Permit No. NCG550000. Please take notice that this Certificate of Coverage is
not transferable except after notice to the Division of Environmental Management. The
Division of Environmental Management may require modification or revocation of the
Certificate of Coverage.
The Ralei�h Regional Office, phone no. (919} 571-4700, shall be notified at least
forty-eight (48) hours in advance of operation of the installed facilities so that an in-place
inspection can be made. Such notification to the regional supervisor shall be made
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone 919-733-5083 FAX 919-733-9919
An Equal Opportunity A�firmative Action Employer 50% recycled/ 10% post-consumer paper
NCG550804
Spoonermore Residence
February 6, 1996
Page 2
during normal office hours from 8:00 a.m. until 5:00 p.m. on Monday through Friday,
excluding State Holidays.
Upon completion of construction and prior to operation of this permitted facility, a
certification must be received from a professional engineer certifying that the permitted
facility has been installed in accordance with the NPDES Permit, this Certiiicate of
Coverage and the approved plans and specifications. Mail the Certification to the Permits
and Engineering Unit, P.O. Box 29535, Raleigh, NC 27626-0535. A copy of the
approved plans and specifications shall be maintained on file by the Permittee for the life of
the facility.
The sand media of the sand filter units must comply with the Division's sand
specifications. The engineer's certification will be evidence that this certification has been
met. .
A leakage test shall be performed on the septic tank and dosing tank to insure
that any ex filtration occurs at a rate which does not exceed twenty (20) gallons per
twenty-four (24) hour per 1,000 gallons of tank capacity. The engineer's certification will
serve as proof of compliance with this condition.
This pernut dces not affect the legal requirements to obtain other pernuts which may
be required by the Division of Environmental Management or permits required by the
Divi �ion of Land Resources, Coastal Area Management Act, or any other Federal or Local
governmental permits that may b� required.
If you have any questions or need additional information, please contact Susan
Robson, telephone number 919/733-5083, ext. 551.
Sincerely,
A. Preston Howard, Jr., P.E.
cc: Central Files
Person County Health Department
Raleigh Regional Office, Water Quality
Pernuts and Engineering Unit
Facility Assessment Unit
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��, i �iion Date: o ��
Amount �aid: �
Rer.�ipt #• ?�°�I ]
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Tax l�aa #:
Parczl #:
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7�aa_�-aa-�aa�-�--� �aa��Il 7���am.71�7�a
APPL9CA710iV FOR SERVIC�S ��
❑ Improvements Permit. (Recorded Lot) - $200.00
❑ Improvements Permit - $150.00
(Mobile Home ReplacemenUAddi6on)
Existing System Pertnit
COMSTRUCT SHALL BECO�fiE IR�VALlD.
1) Permit requested by: (Owner/agenUprospeclive owner):
Home Phone: S'36- 2� SJ — �94 I`' � Qddress:
Business Phone: �
2) Name and adciress of curreni owner: �_�fL'I,
Well Permit
Construction Authorization for Septic Systems-
$150.00/$200.00
Pertnit Revision �Fee - $75.00 �
1� cuNi��NGH��K
3) Pa�operty Description: Lot size: t�� Township: Su
Directions to fhe property (Induding road names and numbers):
4), P'roposed Use ae�l Stnscture Descriptivrac answer each of the ollowing
- a)_ Proposed !� Existing , Type of Stn.�cture: OME S D/i!/L
b) Number of Bedrooms: �-. Number of occupants o people to be
c) Basement: Yes !�/ No Wilf there be plumbing in the basement?
„ d) Garbage Disposal: Yes �/, No _ �
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i,� e .
a 7��5`
/�%N�sdoRvu� H
n: G-'ST,�r� S Lot #�2 5
E /� 7TAc�Y�� �1��
�uestions: "� � �
Width: 7 8. Depth: 3�
served:
5j �'vater �uppiy iype: Private _(new _ or existing�, F'ublic_, Community_, Spring _
Are any wells on adjoining property? Yes_ No _ If yes, pleiase indicate approximate location on the
�site plan. .
, � .
6) Does your property contaira_�reviously�identified jurisdictional wetlands? Yes_ No �
: a� —
Pl.�AASE NOTE TFiE FOLLOWIMG:
. ��'
8 A P�T OE Ti%E PROPEl2TY OR SIT� PL.s►N iUiUST SE SUBiI�I�'TED WITa! T6iIS APPL@CATION.
9 PROP�RTY LIiVES AWD COR(VERS nflUST �E CLEARLY MAf26CIED`.
9 THE PROPOSED LOCATION O� ALL ST9�UCTURES MUST BE STA�(ED OR FLr4GGE�.
9�HE SITE MUST �E EiEADILY ACCESSIBL� FOR AN EVALUATIO�N �Y THE 4i�►LTH �EPARTNiENT
STAFF.
',,
I hereby make application to the Person County Health Department for a sit�e 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 roperty. I understand if the site is altered orj�the intended use changes, the permii shall
become ' alid. ;�
• �
. . , - � / � G•'L
C� ne�r r Legal Representative �'� ate
PCHD, 2v. 06/27/02
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SITE. �BE.TCH
N e ��_ M SAo�n�rrtiorc
u ' 'on �ncs r � E6-f�--�cs
Au�orized State Agent
Tag lYlap # 41� Parcel # �5'
Section/Lot# ��
� 9-�s-� a
. Date . �
sy� �o�o� �� �pro� ��� �ty. T'he contrador mus�, flag the system prio�- to�
begarning tlie instaAa�ion to insure thatpropergrrade r:r maintar.ned �
s�:
m
�
09/12/01
���y )��� � ,a �r�� �.�. V .
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�a'����'n'i+�rn�LaEs�1L'��i..1L ���.JL¢�
WELL PERMIT
PI.EASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: ��.� Parcel # � Townslrip
Applican� 7i M�pQO(1Ct m o f L --
Subdivision: P► n�s bu rpc,�ql� �,� t-a.f cS Section: Lo� a�
Lor�tion: �% �1 l i� J�. i o n Lc �+ c,� e�• u ��� 2 d. � a� �n d
OPi r1C�S � � 0 l.�. % ES'E0.-E.c 1�,� /YlQ l�ctra%S (,.� f—��" On �
�,�,s� 6cForc. C�,l— D� �5�-G�
T e of ter u V Individual Community Public
Re�uireffients:
Si�te Approved by (� �S � d-3�-�z- —
Gtout�ag A roved by ��S � �-3r-�x
t ag
Well: Log ► � -�
D�Tell T ' , _ ..�z..
Air Vent
Hose Bb ✓�
Concsete Sla.b
Well Driller. ��NS �u- � �L��N� .
Well Approved Bp: '►'`'` Date• % l' �� �' �
**See Attached. Site Sketch7jpk
Wells must be 10 feet from property lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from anp bu�ding foundation.
Other conditions• 7n5t� ( I W c.61 t..1 �.c..rc: mur-K�d W� F/a �,$ ct.5 i�ndi�ctifz.d
on 5� �� SK���,
:; ' � PC�ID, rev. 09/07/01
_��: ��_ �� � � �.� �o�
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IE.���-�.n •m���.:��-�..��,.�,.,Lw�,.Ti. I.C-3G`..:n.11.�ll-n.
� �� �
�r��[lar a� � , a . �
C'�pn� a�o ,�i ��c�� %� ,� r. L�h S
D�o D��O�cl _ /� - 3 d .a -�
— w�u �,o�
Owner: _�;�;,�,,�� r�,A� ,,, 1'ax i�Iap�� Parccl f� �-S
Location• —�~�
Subdivision: ,p�,,,, t � , �� �=S���o� Lot 1��_
m� ��a�ds��'w�7
Wcll Coxxstt•iictiozi
Distancc Prom ncarest I'roperty Liiic (Ivl�ii�imwn ! U fe�t) `�
Distance from Septic System (Miniznum 60 fcct) ✓ �i._-.
Total Deptl�: b � ft Yie1d: �_ GPM Static Water Le;vei: _�_ (�
Water Bearinb Zoncs: Dcp[h �oo -�'{-�� t� �-� !t (t
Casi�ag:
Depth: From D to i3. Diameter: 6% in
Type: Galvanized Steel '�
Wei�ht: 13 Thickness: I�b� FIeigt�t above Ground: � r in
Drive Shoc: r/`Yes No Aaiy problcros encounlec•ecl whilc settinb caSinU'? �Ycs
Tf `j�es" give reason:
Grout:
No
Neat: Sand/Ceme;nt -� Concrctc Gravel/Cemcnt
A.nnular Space Width �_ lI1C11�5 W1lCI' lIl A,IIIlUI� SPc1C(: Yes t�(o
Method of Grout: Pumped Pressur� Poured ` Dcptli ` to
Matez-ials Uscd: ( ,y ��
No. Bags Portland ccment t/��-'�` Wcibht of 1 I3ci� �� _ Pounds
If mixhu•e (sand gravcl, cuttings) – Ratio �- to �_
ID pIates: `�e5 No 4 x� slab �Ycs Na
llrilliiib Lob i .�,��,�;.,,. ��.• ...,,.,,.
Ft.
I hereby certify that thc above information is conect and tliat this well was constructed in accordance with re�ulations
set forth by the Person County I-iealtIi Departmcnt.
Si�aaturc �;:� Loutractor _ ID t� 3.l I�atc � o-3 /� o�
PCI�iD rev O1/16/02