A25 206*Block, Brick
. or poured
- _ concrcte box
*Cleanout Plue
*Note: Cleanout olug adapted to accomodate
stand pipe to adjust pressure head, or and
additional tap may be used to accomadate a
stand pipe for pressure head adjustment
1/Z in. Threaded Tap or
saddle tap Sch. 40 PVC
Sch. 80
PVC
Pressure Head to be set at � ft.
�
Taps and
valves
Mechanica!
Connector
Nitrification
lines
pRESgURE hiANIFOLD DETAIL
S1DE VIEW
9
Support Straps
Cancrete Pad. Le� el
END VIE�V
Gate Valve
qin. Manifold
, _ Sch. 80 PVC
From
—�_Dosine
Tank
_� To Nitritication Lines
Support Strap
Support Block
Concrete Pad, Level
TOP VIEW
ig
i
ng
�
��� j�� ���� ��
�y * `V � `lJ J� V � �
IEaa�nm�cna�*�oxa�ln.A ]Hl�e�m,R�hn
Name L�1�1. , Bt�l �R,V i c�
Sub 'sio
uthorized Sta.te Agent
�ITE S�ETCH
Tax Map # Aa S Patcel # aO(.�
Section/Lot#
� C� �3a -oa
� Date �
Syatesn comportents represent afipmximate contours only. The contracMr must, flag the system prior to
beginning the ittstc�lla�ion to insr�s�e that propergnrr�de ia maiHtained
,... e . •� . , c_7
� F��g�m��s i � Lt�lt'�'�kF�z rJGE Z.5 `�'N�S 7r� �c.E'o �- . S f'T'� P� ��-� t
Ipe, �t�t>rc.d -�o a.ec�nnod-�-tc Fa�( f oa. ja��cr eFFl�cnt Qurnb t,�r � l bL
tl �.�d cd to o�-h � cc1 c- P �c-SS ��c, {� t�d and � ress�r� Zt �rnan �° Fo (d ��
_ 3oc�.aq " � . �
-� DD N�T
C�D.�E �02��
��J LDt�E�P.,
-� Kct� t� c,t I i n
(�rc�- 51���
� , � `�Q
Scale:
�
a
� (�(�i,ru-C�-�4 r �hov� � `-' '- 1
� 5�.� rn O u--� � r� C',o�� �`� �r
. y
�pzFor� . i ns-E�i.l [ ► � �YS�'�'
���� �
�iS �rCu-'i n� iS �Q��Scn
F a� roxi rnatc, Co�.�r .
o PP
PCHD, rev. 09/12 f Ol
���1; ,.l � ���� ��
�.. � � � �.1� � � � 1L
�'� nad-na- �m aaa�n c��. �.ffi.� �� � �. �. ��n.
Applicant:
-Location:
N �
.
T�x M�:p ` F'�rcel # , � .
Suibciivision
Phas•e Section: Lot t#
t? of Bedrooms
0
Oper�t�or� Perm it �
System Type (in Accordance W'rth Table Va): b
THIS SYSTEM HAS BEEN INSTALLED IN COMPLIANCE WITH APPLICABLE NORTH
CAROLINA- GENERAL STATUTES, RULES FOR SEWAGE TREATMENT AND DISPOSAL,
AND ALL CONDITIONS OF THE 1MPROVEMENT PERMIT AND CONSTRUCTiON.
AUTHORIZATION. � w � � o$,
- ��— (�1$-05' � �,�.K� c,nlc/
Authorized St te Agent Date
Installed By: J�a-nM�� � �,,,�;,s � � Date: . _ / - /� -OS
��-K..w� �'n,C�'� iZ�
t.xt.11 s;1c
�i------�
(o�.
_ 113'
1 Gw�
i-}vw�c.
�i5'
8- 31-uy
nTl-1 � a
�8-1 N 2
11�1 p-O�I 1:J
f'�-�oo0 1„r
���
25 �
30' `
�• z
a2 � `.� � '12 9v
� �
�' t�' 7 %c '
7'` '?,` �� �
8'y qt�
$'�+ �•�t
q�? �'� ; �' /�'
, , C �
, ►o's
to'S
' 1 42
��'s
PCHD, rev. 07129/04
5�.�'i� �'.�lK iNS���'�H�� C�E�.3S�' (�'� Q- f9� .
Ta: MaQ-# �� i�arc�! # S�ste�ri Type (Tab�e Vaj �-� ,
Own�IAQQ�icant l cr� I„� � �a. Subdivision
Addr�sfLnr.ation � SeclPl�ase _ L�k # � • �
. . . .
• S��c zars�c , r.at�on es .
. St�te 1Dldate - ��S ►�rl �Es /-aS Tt�encft Wtdth 3 ft. ..l8 -
� 9�- i'rencfi. Depth .� 'S �n. ,�- � , .
Tee and F�er � Trencf� Le S�/C7 f�. r�5
Baflie - � � Tr�enct� Grade � �
Seaiarrt � Trencfi S acin
� Riser rF licable Radc D and Qua '
Tank Ou�et:Seai � Da�ISte owns etc, • .
Pemianent Marker i/ Pressw�s� Late�als � � '
. - - � Pwn� Tank • Hole S�aang , . .
^g5 �_ � ... . . • . . .
. CapaatY . nT� - � Pipe Sie�ve • . . . � . . . � �
W roaf lSealarrt � � Tum-u rotec�iors � . . . .
: � � Riser . � � ��tequired Se#bac�ss . . �
Water-Tght � • � Ft�m We!!s : � � . . ;� � ..os-
. . pump- . � From Pro� lines • . • • .
� �taedc Vatve/Gate Vaive . . St�vc�tut'e:�l8asem�.:: � � �
. . -s' cm o e . . . • es ra�r�a e � a . . . . . .
. . ��SIS�nriic��es.� • � � � • . . .: . : . Sur�aee` Wa�ers � - • - � � • - -� - .. _
. Alarrn visab[e and audibie} Pubiic Wai,ef Sup Ges
� E�ecfric� Co �errts Vc�nc�al Cuts >2 ft .
Rate m 2.�►,,,,- Wat,e�- �Ines
Ap mved P AAode� Vei�3e Ttaffic �
BtoNc Under Pump Ad' c�rrt• s . .
P Removai Ro e1Ct�ain . Eas trt af 1!U . .
�Distrii�ion S�js�m � p��
S'eriai Distnbution ' - Eas�ments Recarded . .
ressure
Law Pressure PiQe •
Appr, PiQe Material and Grade
�
�
� pcf�d r�v. 3J'f 31a7
���,�� ���.���
- �--_= �-�- � � ��°�-�-
���.�.�-�.�, �..�-�._����.� ���.���.
WELL PERMIT
PILEASE SEE �'�'TACHED PLAN FOR WELL SITE LAYOUT
Tax Map #: /� � � Parcel # �d � Township
Applicant �n� i3ei, QGt U! d
Subdivision: Section• Lot
Location: ��51 � t �' � �Fc� i!D I, �i r� (�tp� '
5
G2o v % n/v; �.✓isif�j� - G1r�
���9'J ,e�t�o-s,✓• �r/�
Ty�e of Water Sun�lv: �IndiPidual
Re�uireffients•
Site Apptoved bp �' S 1-1��5
Grout�n.g Ap roved by(�.;,,�� a �- JS
We]I Log � � - -� -��
Well T
Air Vent \- a7-�
Hose Bib
Concrete Sla. —
Well Driller. I� i1RN �
Well Approved
/�z� �.�-�' �f�r�v�CC
�
Community Public
Cy3�'�
s
� �
'l-tr, �.� c
__
Date: i -�/ �-'�
Site Sketch'�
Wells must be 10 feet from propertg lines.
Wells must be 100 feet from septic systems.
Wells must be at least 25 feet from any building foundation.
Other conditions•
�, (, �c.(� (�J C. � I CP o "+- ��� M S�-P-���-, ,5�1$-�t.t"� .
t�{�,y C�o' o�srd� �,�•�,
PC�ID, rev. 09/07/01
�
� . �o� o� � 9 8
���;Sf ���:��� a �
_ ' c� � �T��� c�o�p� [� �
��.�-a���,.,�, ����:a ���.a�� D� D�Uf1�1 l-as-o
-a Grout Log
p��; � G Tax Map�f Parcel #o�'�
Location: v � O
Subdivision: Lot #
Well Constrnction
Distance From nearest Property Line (Minimum 10 feet) ��%
Distance from Septic System (Minun 60 feet) / d
Total Depth�.c�� ft Yield: � GPM Static Water Level: a S ft
Water Bearing Zones: Depth ��� ft ft ft ft
Casing: Q
Depth: From 0 to U�� ft. Diameter: �_ in
Type: Galvanized Steel �'
Weight: Thiclrness:� Height above Ground: ��. in
Drive Shoe: _� Yes No Any problems encountered while setting casing? Yes �No
If "yes" give reason:
Grout: �
Neat: Sand/Cement Concrete GraveUCement �
. Annulaz Space Width inches Water in Annular Space Yes No
Method of Crrout: Pumped Pressure Poured �/' Depth _� to � Ft.
Materials Used:
No. Bags Portland cement� ,� c Weight of 1 Bag� Pounds
If mixture (sand, gravel, cuthngs) — Rario � to /.
ID plates: /Yes _ No 4 x 4 slab � Yes _ No
Liner:
Depth:
Date Installed:
Drilling Log
Grout: Installed by:
Location Drawing
��� � � ��. �� ,
` �� �' : � ... _ _ �� �
"�F���.'�� i [' , /
� ����1 �� , �
�� -
I hereby certify that the above information is
by the Person County Health Denarhn_ �_ n„_t
Signature of
that this well was constructed in accordance with regulations set forth
ID # �'4��9 Date !'aC�^'C7L!
Pump Installment
Pump Installation Contractor: �Gt�J1tQ, 77�C �� � � State Registration Number: 1C,¢ ��
Pump Depth: C� ft S hc Water Level: �� ft �,
Pump Make & Model: TC��e�' _ Pump Size and Rating: ��_hp � gpm
I hereby certify that this pump was installed and the well head completed according to the Person County Well Rules in effect
on this date and that a copy of thi r� been p ' ed to the well owner. .
Pump Installer S' tu�re l Date: "�' ��PCHD rev O 1/27/04
Type III (b) System Inspection Checklist
Tax Map � Parcel #: % O(� PIN
Owner: .� a Sn n f(��� n Yl Subdivision:
Address: Ph/Sec/Lot:
Location: ('�n�n�
1)
2)
3)
4)
Establishment
a) type, size and sewage flow in
accordance with permit
Tanks
a) tank risers accessible and surface
water diverted
b) tanks and access manholes structurally
sound, watertight
c) sanitary tee(s) in good worldng condition
d) tanks pumped, cleaned out as needed
Effluent Dosins Svstem
a) effluent appears clear, free of excess solids
b) required pumps present, operating properly
c) high water alarm present, operating
properly
d) floats, pipes, valves, disconnects in good
working condition, operating properly
e) control panel enclosure and components
in good condition, operating properly
fl Drawdown rate:
Ground Asorption Field(s)
a) no evidence of effluent reaching surface
or surface waters
b) surface water being effectively diverted
away from drainfield
c) diversion ditches, swales, tile drains are
well maintained
d) soil cover, vegetation adequate and
maintained as needed
e) protected from traffic and destructive uses
fl distribution devices in good condition,
working properly
g) repair area properly reserved, maintained
h) pressure head properly adjusted
YES NO Remarks
� [�' [ ]
(l [J
�J � �
[]
[l
��
��
L/J
Summary of Improvements and/or Repairs Needed:
Authorized Agent Date 7�/�i � /�
Q��
Person County Health Department
Sewage System Improvements Permit
Date: 3���`This Permi Void� �t 5 Ygars �• �-
Owner: _�.,� V O�t1v1-i-P�Y7 I ✓C �$R# ��
Localion/Directions:
Subdivision ame: � t Lot #
Lot Sizc: - T � I��►ell'n .
�Y� �r�,�,�P
Water Supply: Private: / L'J'[tGIIc: .' mmunity:
Bedrooms: Garbage Disposal���
Basement Basement Fixtures r
INFORMA .D B _1
Sanit�l�ll: ow er or representatl�v - ..+"
REPAIR: REEVALUATION:
Size of Septic Tank: -.��y�- gallons Si�e of Pump Tank: ---
Nitri�cation Line: � �✓ � `
Depth of Stone: 12 inches � __
Max Depth of Trenches:
Altemative System: Conv, Pump PP m �
Remarks: � �� .
.,
;:
y; � � �
z ,:
r;
� t:
�
CD F�
;: �
f
,
�
r, ,
�
i
;
�.
0 � .
i
G ;
�:
i
�
1 ,
--{�y-Ll��—`�-_-----�.."'-�-�----------
Date Well Approved: Well should be 100 ft� from any sewer system '
BY Sanitarian
Date S e Ap ved:
BY Sanitarian
�--� R'TIFICATE OF COMPLETION
Contractor. —��
� --- '�
Sewage System location, installation, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained �
by owner in such manner as not to create a public health hazard. Septic tank and`d
nitrif'ication line must be inspected and approved by a member of the Person Counry �
Health Department before any portion of the installation is coyered and put into use. If
ihe site plans or intended use change this pemut is subject to revocation.
(G.S.130 A-335F) ,
Location of sewage disposal sewage system sketched on back.
(OV R) �
�� . ;
��� �- f�.. .
�.a n C
�
Sketch well locauon on reverse stae. - "-� "" ' '
.
r
_ tanks. PTivies, water
house, septic be l�ated
location of installations maY
....w.,winB lot size and_ .,^oasurements in order that
NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
. . . . _. . . - -r ------- -•---,:.._ .... .,a;..,,o..« �.,.�
0
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