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A24A 44r� Person County Health Department Sewage System Improvements Permi :��y�This Pe it Void After 5 Years —�+ ��e?� �� c+.r� � �r��A� n�� r'_ /.'v .�f..� Al. �IY� SR# �L � Subdivision N e — Lot # ��.ot Size: P Type of Dwelling: . ' Water Supply: Privatc: Public: Community: i` Bedrooms: � Garbage Disposal `; Basement Basement Fixture ` ` INFORMA R D BY 5��: owner or representative REpAIR: REEVALUATION: z � � -------- -------------- Size of Septic Tank: al ns � Size o� Pum Nitrification Line: � Depth of Stone: �2 inches __� Max Depth of Trenches: — �, Alternative System: Conv. Pump ' � LPP Pump Remarks: Date Well Approve ��—/� %aWell should be 100 ft� from any sewer system BY Sani Date S ge st pproved: �"/�� cl o BY Sanitarian Contractor. , - ---------�---------------- � Sewage System location, installation, and protection must meet state and local � regulations. Sepuc tank should be pumped out every 3 to 5 years and shall be maintained .��- by owner in such manner as not to create a public health hazard. Septic tank and'o niuification line must be inspected and approved by a member of the Person Counry � Health Depaztment before any portion of the installazion is covered and put into use. If the site plans or intended use change this permit is subject to revocation. (G.S.13U A-335F) � Location of sewage disposa�sewage system sketched on back. (OVER)` �', . - Pe'rson County Health Department � Well Permit � Date: � This Permit Void After 3 Years �� Owner: SR# ! , � � _ /_ _ _ �—T— LOC1Il0I1N1teCIlOi1S: � �% ns L1 / � �4� - - - Subdivision Name: Lot # Drilling Contractor: �(�,,�g S l�t�%� �,�� WELL CONSTRUCi'ION ►� Distance from Nearest Property Line1 ��1 /u.s Distance from Source of Polluvon �� d A � C�' ;; Tatal Depth: ��Ft Yield: (� GPM Static Water Level ��F� Water Bearin g Zones: D e pth �FG Ft. Ft. Ft. Casing: Depth: From �_ to d G Diameter: 6� Inches TYPE: Steel � G vanized Steel v� If Steel, d owner approve: Ye No WeighG .� Thiclmess: Height Above Ground: _.�7cInches Drive Shce: Yes L� No Were Problems Encountered in Setting the Casing? Yes No �� If "yes" give reason: � Grout Type: Neat Sand/Cement Cancrete Annulaz Space Width � Inches Water in Aimular Space: Yes No r./' Method: Pumped Pressure Poiued L�� Depth From _ � to � Ft Materials Used: No. Bags Portland Cement � Weight of 1 bag : �'� lbs. If m'vcture (sand �avel, cuttings) - Ratio: a--- w � ID Plates: Yes ✓ No ►� 4 z 4 slab Yes � No � I HEREBY CER'TIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET FORTH BY THE PERSON COUNTY HEALTH DEPARTNIENT. Date � ��3 no ISSLICd Sanitarians Signature Date Completed Sketch well location on reverse side. �-1��.�� d � oo.�� . . � ,��ii�tion Daie: jP . � � � T��, �fJaa� ,�� ;�avtoa�ni aai�: ��p � . f ��; 6 • ' (l� ��—.�a..$ a�t . ��, .T - i � - . • �srson•Cauntv �eaith De�aartmeni . : ... . .�., . ;:;�nviconr¢��rrtai Health Section • . .. ' '`;:. APQL'1CATION FaR SEi�VIC�3 . :;:��;: `:��`:.:., � ��. ,� - C �� '.:.. 1F TNE 1NFORMATtON IN THE APQLICATION FOR AN iMPROVEiNENT PE3�AAIT_IS_FALSIF�ED. Ct�ANG�}. OR THE S1TE 1S ALT'EiiE�. THEN THE IM�liOVC-�AE�IT PERMIT AND AUTHORlZA170P1 TO COFISTRUCT SHALL BE�OME 1NVAl.ID. 1) Permitrequesbed by: (Ownedager�Uprospeclive � � Home Pttone: 33b -231-1� -�Z l O � Bueinesa Phone: 33b ��t-�SO� /� 2� 11��ftA 8flt� ��59 �Of Cii[i�Eflt / �_ : '(.,�nGL+r �S � '�/ i ryt,Yy� . O 5 �tl�l ' �n I� �,�re � v� s d�ro r� c z`�-L(�3 I� �s-ta.-I� � CS�QQ f-� 331��3�-t313 5 3j Property Descr3ption: Lat slzs: ��, � Towns . . '1G,�� • . � Direction� to the pro (indud'irt�ro^d�names an r�nbe ): . :. �l �0 5 S S V�3r 2 b r c .e 5 c�.IC.� '�.-t- '�-t-} � �,(� u.rcfn �� te� � (p.,�,.�sb��-�� ta-� f� . �rd� ►zc�� ''�'-�. 4) Propased Use and Strueturs �escrl�ltton: answer earh of the foliowing ques�ons: �� rr� a) Proposed 4 ExIsting�_ . ��il vc1 . b) Sddc Bw7t'� Moduiar O,`S;Pgle Wtde �, uble Wide ❑ . c) Num6er of Bedreoms• ,.�, .�'�'°�-a�� cn Number of accuparrts or people to be served: �- - .. � �). ..Hasesner� : Y�es� O, No�S.lf yes. # af basament fnc6ures: . . . : . .. . � . - _ .. _ � = - -- � � � : � �' 6arlaage. Dispc�:'(es � y��.Y- -. � _:�•..� .,,� .. .. ...., .� : .._ .. .... . . . . � . .�.� . _ _ -. - � _ . .... . 9) Dimensions of Pr000,s, e�i Structu�e: Width: Depth: �I � ��C"' � r�� L� V � Water S�ply Type;. Private a(new � cr existing'�, Pubiic q Cammunity Q Spring ❑ . • Are acry weils cn adJoining property� Yes� No � If yes, location �) lndtc�ia De9ired SysLem Type: Conventfonal _aHcdifled Ca�vetrt! other (sp�il: '� )C(�Cl u a � I �-�.y�su-- � 1� e,� �- C � � ,eo( ro o M {systems can he raniced in order of your pr8fei�enca) � .� 6� i Ce mal _ Altemative. tnnovative � . � G`G�,,.�,. �'.- '� . , . ��- �.t�...� �,,�., ,�.�� w� ►�-,�.�.... � �.� . CLEl�RLY STAKE ALL C�RNE3iS ANO UNE3 OF'T�iE PROPEiiTY, r�� STAKE THE CORNERS OF ALI. PROPaSED STRUCTURES. PLFASE ATTACN SURVEY PLAT OR S1TE PLAN TO THIS APPl.1CA7iON 1 hereby make apQlicatiun to the Persan Cacuity Health Department for a site e+raluatinn fcr the an-siie sewage dispasal system fo� the above-descxibed property. i agree that the cairterrts of this appiic�tian are true and represerrt' the maxirnr�m faaf�s to be placad on the properiy. I understand if the site is aitered or the intended use ctianges, the permii sbail ba�ame invaild. 1 understand that as appilcarrt, ! am responsibie for iderrtifying and marking property lines, comers and maldng the siie �ssibie far the persannel af the Persan Cowrty Health Departrnerrt to canduct their evaluaticns. I understand that I am responsibie for notiiying the aith Departrnerrt ii roperty caatains arry wetiands as designated by the Army Corps af Engineers. � � �-�3-01 � Own r Legal Rapresentative . Qate � pCHQ, rev.10l12199 Application Date: � 8 I �� Tax Map: A� 4� Amount Paid: ---� .r..; "� Parcel#: �_ . 3D Receipt #: � � u I � �' � �� I�;�m�aa-��.�m=n.�,�,.11 'IHi��.11�. Aaalication for Services Services ❑ Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 Eod) 0 Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of system permitted) ❑ Permit Revision $75.00 ❑ Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 � pplicaat In P�rmation: Name: Y1 IrY� Phone (home): �33� - a3 ��$� �d Address: s ,(work/cell): ��,�� , 3 � q—��..5� 2) Name and address of current owner (if different than applicant): Name: � Phone: Address: 3) Property Description: Lot Size: A.dciress and/or directions to_ n Lot #: -- 1 e �-�- d ❑ yes � Does �f'ie site contain any jurisdictional wetlands? � yes �y Does the site contain any existing wastewater systems? ❑ yes C�no Is any wastewater gaing to be generated on the site other than domesric sewage? ❑ yes ❑ no Is the site subject to approval by any other public agency? ❑ yes C�iio Are there any easements or right of ways on this property? (if `yes' is checked, please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: '�❑ Expansion of Existing System if expansion: Current number of bedrooms: � Repair to Malfunctioning System Will there be a basement? ❑ yes �-ho With plumbing fixtures? ❑ yes �� ❑Non-Residential � Q i( .3 O �l� Type of business: Total Square footage of Building: �� p�Q � Maximum number of employees: Maximum number of seats: et��.___f 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes ❑ no �If applying for `Authorization to Construct', please indicate preferred system type(s): ❑ Conventional ❑ Accepted ❑ Innovative 0 Altemative � Other ❑ Any I cert� that the information provided above is complete and correct. 1 also understand that if the information pt-ovided is inaccurate, or if the site is subsequently alte�ed, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) �` Supporting documentation required. � ' �— Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A corapleted `Lot Preparation' form must accompany any application requiring a site evaluation. (10/i l) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) 4 � , � :� � '� I' ' `_`� �� r � � �� '� ) � �`�, , .�� „� � `' ! ° .a'" y.- .7 � `�-�'� � �� l ��''� ,_., , , ,. :�,�.�z-y-,i��c�_r��ra�.��-�.�1:<� �. . �.�""�,��<�n. �' . �a�a�a�� s��m��/ l��bn�� {a�a�� fl��a��n�� Tax Nlap #: �►yA Parcel#: y�1 Address: I�`I P��sA�0.o�t� �tsr• �2�- Approval Requeste�i ior: Mobile Home F'ceplacement � Building Addition Applicant Name: e,�Acu.r� C3't(t�.��. Address: (�`i Q•c�,st�cs�o..uoia �-+� � � Phone #'s: 33b- �3�4 -�3�c a 33►e - 3�l g-�! b�4 Permii Located: i�. Yes Tlo Installation Date: $-34- O� Design flow: 3�c0 (gpd) Cunent Centract with Certified Operator on file (if required): 1, P• . Water �upply: iC Well Public or Community Wastewater system shows no visual evidence af failure on: S 9 1'� (3ate) (Applicant's signature if site visit is not required) Comments: �Pi'twJt��.. t�. 7-0 ` X 3�` S co�bF. ��b ��1��/��aa� t��p��1 o�.0„�.1� Q . .�.� Envirorunental Health Sneciaiist 5�� t� Date PeYson C�unr�i Environm�:1C3I �Tealth; 3�5 S. y:orQan �t., Suite C; RoYboro, NC 27�73 Fhone:.:�b-�47-??9C/ra:�: ��-�9�'-780� � ��:v�ji.�exsoncotm�tv.i;et ��5��9 ��3l�i��f ��J��3R�6UiE��1L �1E;�L.3�3 S� .5�� A�"f.�C�lE3� ��,i�� IL ,��,s� �,N� �`�ST�� L�'�Ol9T Tax Map #: ApPllcanC ��/�QS ��2iOKJi e .L.)U /'U r1'i Locanon: New Addition ✓ !r� rovement Permit. U )�^� e- y�!3 �.�; � � Type of Structure - p1'�� d��r irt�,'n_I # of Occupants �� # of Bedrooms 3 Other �' Projected Daily Flow: 3Co D g.p.d. Permit alid For. iv Ye� Proposed Wastewater Syst m: a-�' � o?S �'P Proposed Repair. : Permit rr�� ,e,�',�, Water Supply �� 'rx G�% System Type� � ,� � �� I I-36-6 J Owmer or Legal Representative Signature. ,� �_ � 2_C A �+-�. Date: Authorized StateAgent: Date: //-�q-O/ The issuance of this permit by the Health Department in no way guarantees the issuance of other per►nits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requinements. This site is subject to revocation if the site plan, plat, or the i�rtended use changes. The Improvemerrt Permit shall not be afFected by a change in ownership of the site. This permit is subject to compiiance with the provisions of the Laws and Rules for Sewage Treatmerrt and Disposat Systems of the North Caralina Administrative Code. Wastewa#er System Description: Facility Descriptiort: Basement? O Yes" v� rQ�r Wastewater Flow: 3ti0 g.p.d. Type:� � Yes 9'1Vo New O Repair ❑ Expansion � lMastewater S tem Re uirements F�c,'s ii�trj) �iV e�.J� Tankage: Septic Tank size D� �gal. Pump Tank size /oon gal. Grease Trap size -- gal. Te�enches: Total length 3p� ft. Trench �dth 3 ft. Total Area _ �D sq. ft. Max. Trench Depth: �� in. Aggregate Depth: / a in. Soil Cover: _� in. Trench Separation �ft. on center Permit Expiration Date: � a1 % -Dl� Authorized State Agent �� Date: �� 4/ *See attached site plan and addendum pages for additional pennit conditions. The iype ai system permitted t� does � does not difFer'irom the type spec�ed on the application. t acc�pt the specifications of this permit _ �� Owner/Legal Represerttative Signature:\�� 4�-�� .�,�_s Date; � �� % ��eration Pern�it System Type (in accordance with Table Va) �� This system has been installed in compliance wifh applicable iVorth Carolina General Stahtbes, Laws and Rules for 3ewage Treatrnent and Disposal, and all condfions of the Improvement Pem►it and Construction Aufihorization. Issuance of this pertnit implies no guarantee t the s rstem insfialled wiil funcYion property for atry given period of tune. '� �r--,3� � O � . Au orized State Ag t ' Date PCHD, rev. 03107/01 ��`��•`- � ..2c� � 0 iTEl�d� 4X Saap7ax Cos�frolPaaet � �� Dmet SeatHoth �" $ 4" Pressar Tzeated Post I Eads Qf Thn Cotu�t Coxoc:ata &ves .• S7oped To S'imd Witas 12' Sapuatioa Z4" �.' . � Elactacal Co�sst •. . � - • 6" Sepuaticn , Tlaeaded Gate Yalve ; ' �' Acce� Cover• .• ' f ' ' 1 �� ' • ,' � %�.�ct' . S" Cover • ' • • . • _ ' � Portlund Coaesets Gzout r . ' • • � • y ` � r •. . ' �„t � ! :. �yl�1C • . _ . � �. : , t t �:., ..'+. • �, 1 � •� �' � q,,, •". ' •`�•• � • • � "'Y COtd . . � �E�Ig � �1�1 . �,. Opexn� F�11ed With p�}i Sipluon Hola Ties S�FP�9 Portlaad Caiaettt G:oat In1et Fzom Septic Taulc ortlaad C�m�xt � �� l • � �� Oat]at To D�n +{" SCH +40 PP� Pipa "'� Cl�mck �y� a" SCH40P9C Pipe Y:lv. � P7oat Fv'ue� ' � • Higk Watps dlarxa I.av�l . r , , �6• �p�y . Sitii Lav�l- P�p Oa ;. ' .% +�Vapo:Lock F7aats .�• . �� g,�• $o1e • •• :,�� '� �fIIP�,I �i7�o tT t ,. � , I.ow L�vel-Praap O�' . „ _ � g�p . . - ---- .'. 5 , ' �: ' Preca�t Cornxete Ta�nk 4" Concrate �� PUNP BAYING � . '.;� eaa1S �3500P � ` � ' ..i; ' � , , . Pump Mnst Be Rated 7o deliver ','ti.;� .' . ,. ' ' ' • ', . .%• • . � ti � • ' � ;` t o�C� Galloas Per Hiaute ' ' Against o'�,S Feet Of Tota � 6D� GAt,LC�NFU.NIl' TESiNK Dyna�aic Head (TDH) . uiaiusuiu�.uuu a� www.uCi1.�I1T.5ISiB.IIC.i1S Fitting�to allow fo� cunnacting� dear pressure monitoring tube (leave tube in bottom of vault) �luminum ar #eel � � shoebox-type covers wftli i�sndlet (150 lbs. eaah, max.) , _� Support straps or bars • Manifold supports � �. • • • • �� . -i� � Dead level mmifold instsllation Gnve! pit for internal.drain disd�use f'ag�� ot�' I'rofi�e View of Pressure Manifold for Siopa�g Site Installation (not to scale) � _ " I Tap - di:nct tHread or sad�e � Pressui�+e head ehec]c ft�ah wii�t insida ws1�1 or. trl�t �-.. � �I�esnal vmilt drafr� Mffifif07d 4971It o n n o 0 0 o a Tnta�tia� bsII VHtVO (ball valve with taoo disca�ec! �) � 1 1 1 1 1 1 i 3"�� Obse:vffiipu poxt (�ea vvith extension to draMlines a� min. 1.0'Xe slape � bivagi�t to giade; with rmwvable cap) Plan �iew of Pressure Manafoid for Sloping Site Installa�ioa� (not to scale) http://www.deh.enr.state.nc.us/oww/LOSW W/manifolds.htm 10/18/00 YF9 �.essu_: treated ".•�.• �7G5� •?: ?QG:.Y3:8Q� �. HS� �% . «i .� 3nclo�ure � i�ater tiqht � + corrasian ;stall ? ci;cuit [esist� � .scannect svitcfl � � panel does �ot :Y� a dead frant : .._..._:� � �� ianaal �isconnect. ._. : - . ote: A 6reaker d�es ::��••� : I � canstitate a , ` sconuect� > t�• ta fiaish qrade inap �upply ci;cai� � 31ars C::cait . �ater `_qht �zai � 3ydraulic ceaeat� � _ _ —� Schedule �0 ?YC ;upnly �— -- -- �i� back pluq and ReceptacZe _ �,. gzg ptessnre treated �� post or eqnivalent �lBxA �Y. 3��=�Sutn �at c � i9at . � cactasiaa resist�t " � 2' iiniia� Gas 'iq�t Condait >Ii' to finisti qrade , paip sapplp circnit alari coatrol � �. �ater Pight Seal Hpdraalic Cenent � � • --- —� Harness �:cess Ca:ds — — ._ . � Sch?dule 49 °VC � � Sagpl� Sim lex Control Panel With Built In Alarm xote: lbis is nat a viring diaqrai! Consalt an glectriciaai -' Dnct Seal � 3eceptac:e anst be aatar _ated �ov-valtaye aiara ' connectian Oact Seai �� 0 y � jackiaq S;._a�s Taraess �zc�ss ��.i� :w�e ��L3 3CS�`. �il2 �OQIl�'.� iZ :52 �:7:�3?� livi�q ;;ea �si :he dve'_'_:sq ;not ia t�e craYi space qar3qe ar nnde= a ao5ile �one; P�e rarel �nst be aa4��e and ?:si5ie to systei :sers �I� Lackiag straps • ' n �� } � �1� ?� )� �� i `..-. _ � �--t — � � �..�� f �iaav>ns�aa�a��cn.�m�. �i0�.11��. I SITE PLAN Nanie ��5 Q`{P-�iM Tax Map # ��Pazcel # �Z_ Subdivision Section/5�9 1 �U�. !'1. Sr.� I Authosized State Agent Date System compoamts teprumt zppmadmate cantours only. The contraaormustllag rhe system pdot to beginrt; e the iastailation m insure thatpmpergrrde is maitttaiaed. �..�� .1�� ``�' } � �C � ��T�� .�� .��.�. ��.�� SITE SKETC�I Name rl�s � �e ,'��u /'u �� Subdivision � E� �s�� G Authorized Sta.te Agent 0 t I 0 Tax Ma.p # /�a `�ttParcel #� Secti.on/Lot# i' /I-�9 Date !o` � fea.. � „rt; f � af �i � ��an; t,�s5``� ---�_,_w _� . / ,�rl I � \ `�% ,�� / �, _, � 'I� S {�m �` ! e %/ anes �� —,3 �iheai' �7 � �nno✓a�f,'ve ,Z��o �ed��h�'it� � nn �`Sbt 1"e ��1 r��(��rS�/'� pcc �i Dv► r ��'U!1p � J�%C.7 � !�f" �-�• �/�� oi� s,�e . � l;nesQ�� T/aq/ Qi � �e ;r n�. ,n.�s .� 200 1 n �� • �g � � reatme ��P� `"�ea� W,�k �rcf @ i8„ de��, / � L�nes a/� '��j�Qc�O/1 5'�% � � � (��`�� \ _ � _ / a5$� ,��11 � I_ r� � � `�'i � �, ' � i �;� � ' �; � � ; �� - �� --'�, � .v• . — ;t i `�� .2'.'Sc � •_ �f %'��'on � � _� �� s�� ``� � F�,s f,n� . �jo3 � �c � Horn� �� "� , �. /�9 � \ I ��,, j�O :,s / 0 \�--- / n`° 1%��Pi�um -f'v ��r� P�� , � J ��'.��ona � / �r�h,'� (.dna�'�6izs .�— � — � Fol%W �ysr�Ps� /a� o�t-� c�.�� , T,�s� 1� �r��%es on �,,,,�ur, T�F �Ia are r�;ss�n� or �vec� C'�� . �'��.D r ,� > �N t!, /�7lPcc �%� D ' ,��. 2) On-s.i� C��'eic-C_e. wi�� ;�s-{c�//2r a�a� �j'� .D, �r�v. /�ai�/ � ,� jS tequirP Pi�r �D i/i/1i ins�a//��h . � [ � � � 3� �G�d�ur�i ��s /-�� -�i� �u.m�0� �ressur� ,�za�ir'o�� L�L�ro%ii�% ��'C�e�'�o,�.s; s��e: �- `'=S�'