A25 220� � � ��,q/��
Application Date: d �
Amount Paid: o2do • U � 360.
Receipt #: �I 3 9 �� ( 9�S
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Ca1r� App
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/Repair)
$3 00.00/$200.00/$75.00
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lication for Services
Tax Map: Aas
Parcel#: -�c'
2�
Services Re uested
Construction Authorization
(Fee is de endent on the e of s stem ermitted)
Permit Revision
$75.00
Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1 Applicant In r ation:
Name: ���� � s/e'
Address:
2� ) Name and address of current owner (if different than applicant):
Name:
Address:
//, ,�-���s
) Property Description: Lot Size: � 7`/•%Z Subdivision:
Address and/or directions to Property: �'"% ,Q��
Phone (home): O,',���— T �� � TS�
(�dcell): o'��o'�— �o� O3J��o
Phone:
Lot #:
❑ yes no Does the site contain any jurisdictional wetlands?
❑ yes ❑ no Does the site contain any existing wastewater systems? �
❑ yes L9 no Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes ❑ no Is the site subject to approval by any other public agency?
❑ yes ❑ no 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 Ma�cimum number of bedrooms: *�S
❑ Expansion of Existing System If expansion: Current number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes O no
❑Non-Residential
Type of business:
Ma�cimum number of employees:
Total Square footage of Building:
Ma�cimum number of seats:
5) Water Supply: ❑ New well 6d'�;xisting Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6yIf applying for `Authorization to Construct', please indicate preferred system type(s):
� ❑ Conventional ❑ Accepted ❑ Innovative 0 Alternative ❑ Other ❑�y
I cert� that the information provided above is complete and correct. 1 also understand that if the information provided is
inaccurate, r f the ite is subse ently alte ed, or the intended use changes, all permits and approvals shall be invalid.
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S gnature (Owner/ Legal Represe tative*) Date
* Supporting documentation required.
• Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat.
• A completed `Lot Preparation' form must accompany any application requiring a site evaluation.
(10/11) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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�aaw-a�roaa,•�,•�,• a�aca��.� ���om.�.'��a
Sloped To Sl�ed Water
6" Covas•
i.,
Ixdet Fmm Septic Tank
- +1" SCH A�0 PVC Pipe
NEMA 4X Simplex Coatml Pazul
�" X 4" Pressnre Treated
12° Sep�ratinx
Elect:ical Cos�uit =
0
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• � ` Access Cover• � • ' ' • ' .j � ;
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�,, Opening Filled With �`• �ti Sipkon Hole' •
Portland Cement Gs+vut `
— (Drnvx Hill)
Cl,eck
• Valve �
High Water A]axrn Level
(6" Separation)
Hi�lt Level- Pump Ox -.��
;� �� rVaposLock
' S Drawdown Ho1a _.
. .; � �p H�,
•Law Level-Pump Ofi --�-^'
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• ' Pxecast Concrete Tan]c
;•; (Mate:ialStrergtk>3500
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T�x M�� ' - P�rcel # - '
Siihclivision
IFIi:�•s�e Sect�ion Lot #
Ikut SealHoth
Eridi Of The Conduit
"' Z4" Ivluunwin i
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Threaded Gate Valve
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Zip Coxd
Ti�s t
4" Concrete
�� Block
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Concrete Risex
�" Separatinn
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�,:.�-PoxtL�nd Concrete Gsout
. _: Mastu � • - •
� Opetiiag Filled Witk
�pply • . . Portland Cemex►t Gmut
riiie • ' '
Outlet To Distrbuti�ox
2" SCH40PVC Pive
1e F1oat Wizes � �
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Floats , ,
�Removabls '. : '
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►ova GAI.LaN PLT1VlP TANI�
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Pnm Hust Be Rated 7o Deliver
�� Gallons P�r Hinute.
AgaiRst 3`� Feet OE Tota.l
Dynatnic t�ea ) .
1E;�.-�.a-�� ���¢�.u. �[�[ �.ffi..u,� Owner� C��w�s R. s�w�s s'�.
Tax Map: as Parcel #: � Date• -13--►5
Line T�ga Tap (Scfla) Tap �lop� �e Length �+'�oe�v / foot
# Di�neter(vn) ( m) �;. ft)
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ao� ft of line x 65 gal, per 100 ft=��� . ►3ti� =100 = 13'� gal
75% x�� ga1= 9'1�S gal per dase �� gal per minute (gpm) = I+'!ow Rate
Friction �ead
Loss: I.'1$ ft per 100 ft of supply line x"�'� ft of supply.line =10� _�•`�� ft
y ��5 ft x 1.2 = S�h ft of friction head �.
IVlani€old Size: a "�'orc� Main Sixe: a " PVC
��otal Dynaa�aic �easi = Z6 ft of Elevation head +�_ft of Pressure head -!- Cn ft of
Fricrion Head = 3`i TDH
Pamp Reqaairement: �� GPM @ 3`� � ft of Head
Drawdowna 9'7' 5 gal per dose ; 21 ga1 per inch = S inch drawdown per dose
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Sz:e 1L�u¢rial FTow GP?rl
?, " Scfied 30 �..i
!. " Sched �0 7.1
/" 5c1 eci 80 I� l
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Applicant: 1kA4�
Address/Location: S
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R, s-�►' S�
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Taz Map: �as Parcel:�_
Subdivision
Phase/Section/Lot #
Improvement Perr�it
Permit Valid for: Five Years �_ Non-expiring '
Type of Facility: Mctpt.� 4�t�1�►E New� Addition _ V�'ater Supply: '�S:t�� W'EU.-
Number of: Bedrooms / Occupants � Employees / Seats: Projected Daily Flow: �l0 gallons/day
Proposed Wastewater System: 1�a�.c�.Q cs�i� `^+ aS `�� '��4��rivr� Type: �S3�o
Proposed Repair: t�.�r'+t' A�q w�`�o -�� Type: ��
Permit Conditions: r►���h�'� 5� � Sv�L 'D�s�.�kc1�C W� ��a� "�� � ��.. QC�O
� CSU.cGsz,�S C,33b�159`1-1�190.
Authcrized S�iate Agent: 'D�'�e:�.
(X) Owncr or Legal Representative:
Date: �I•►S-IS
Date: -- , _
The issuanoe of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applic�nt/property owner to insure 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 lmprovemeni is noi affected
by a change in ownership of the property. T6is permit was issued in campliance with t6e provisioas of the I�Torth Carolina °Luws
and Rules for Se►va�� Treatment and Dunnsal Svstems'(15A NCAC 18A .i9U(1). Neither Person County nor the Environmental
Health Specialist svarrants that :6e septic system will c�ntinue to f�nciion satisfactorily in the future, or #hat the watcr supply will
remair �otabfe. _ _
Authorization to Construct VVaste;�vater �ystem
See site plan ar:d additiofzal attachments �_).
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Proposed Wastewater System: t�.i�4 A w�,-p�.'� w) �10`�'' (*1Type �A� Design Flow a�'4 _ gal./day
New � Repair _ Expansion _ Soil L'fr�R: n� 3a gal_/day/ftZ
Type of Facilit-,�: �-(�, 1"�r.Y�i� i3ety� Bssement: _ Yes X, No
(*) System Types Illb, Illbg, IY, and V, require periodic system inspections by th.e Ferson County Health Department.
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Wastewater System Requirements
Tank Size: Septic Tar.k IOOV gal. Pump Tank 1�0o gat. Grease Trap " gal.
Drainfield: Total Area b� sq. ft. "fota.l Length aQa _ ft. Max. Trench Depth 1'�_ in.
Trench Width 3 ft. iVlin.Soi( Cuver � in. Min.Trench Separation g ft.
Distrihution: Distribution Box / Serial Distribution__ / Pressure Manifold X
Specifications:
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, 8-�V►, AA��-�1vr�_ SV��- GovE� �,'C�1�vcLKai
Authoriz�d State tlgent: r7. �Rtt�c:�.. �• 5r� issue Date: �}-L5-I S
Permit Expiration Date: `� -15 - ao
iiilqQ
T'he system permitted is: Conventional /Acczpted �/ Alternative / Innovative . I accept the co�iditions
and specifications of this permit. � �/� ��
{X) Ovvner or Legal Representative: Date: � '
Person County Environmental Health, 32.i S. Morgan St, Suite C, Roxboro, NG'?7573/ph: 336-597-1790 (rev 5/12)
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Applicant: C�av�� ��►�- �':
Location: � } , , �,�
System Type (From Table Va): �
Type V& VI Expiration Date:
Oueration Permit
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Tax Map ��� Parcel # ��`
Subdivision
PhaselSection/Lot #
# of Bedrooms r;
Product (IIIg): �-�Z �� �''�
Type V& VI Renewal Date:
This system has been instalIed in compliance with applicable North Carolina General Statutes, Rules for
Sewage Treatment and Disposal, and all conditions of ihe Improvement Permit and Construction
Authorization.
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Scale 0'"�-
PCFiD, rev. 12/14/12
Tax Map: Parcel #:
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Septic Tank System Checklist (Type II-I� System Type: ���� �
Notes:
Pump System Checklist
Contracted Certified Operator (Type IV Systems}:
Notes:
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Legend
� Existing House
7 I Dnp Repairfor Existing House
� Proposed 2-BR SWMH
� � � Repair Lines
System Lines
� Septic Tank
O Well
Q 50 ft Well Buffer ��,
� Dnveway
� Roads
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System
" 2 Bedroom (240 GPD) * Minimize site/soil disturbance when clearing system area.
- 200 In. ft. * Divert gutter water away from system components.
- 14in. max trench depth * Bury supply line at least 30 in. across driveway crossings.
- 0.3 Itar * Contact PCHD with questions (336) 597-1790.
- 8 to 10 in. additional soil cover required
125.980162
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219.6336g5
ARCHlE CLqYTpN
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A25-32A
Charles R. Stewart Sr.
POND Archie Clayton Rd
4/15/15
Authorized State Agent: Derrick Smith
357.429731 ��8.881495 100.199005
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