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A25 28( ,,�, k 1` ��',+'� W PERSON COUNTY HEALTH DEPARTMENT ' WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # �_� �% Parcel # 3 � Zoning Township Owner/Contractor C ,L, Date� �— a/_ y� Location/Address � ° � i 1 � � �n ��t Subdivision Name Lot# �yo�c , . P Q �a „�. �� s h Cf oY �� o y �y �� s�� t �'r� n�. c,✓t�� wi� d„�:��=e,t�• .S�l�.`f nr�t i n�ila .; A 001203 �� I � �� 1 n S� 3� vF- 7�� S[J") SEWAGE SYSTEM SPECIFICATIONS InJ�1en ''��v' �vil� o ✓ /�ea`�d Repair Lot Area (01' GL�vP�' Size of Tank ��`��` ' c{✓�. SFD Mobile Home Size of Pump Tank � Business # of Bedrooms Nitrification Line � ✓ roo�h ' �' � �, Max Depth Trenches � �� Permit Void after 60 months. Pe it Void if not in compliance with zoning regulations. Permits may be voided if site is altered or inte ed e hanged. Well and Septic Layout by Comments: _ � Date Site Approved Well Hea� Date by R� ec�d Slab _ �Vent Required Well Lo� Well Tag __� Approved This repoR is based in part on information provided the homeowner or his/her representative in the appiication submitted for this perntit The environmental health specialist is not responsible fcr false or misleading information co�ained in the application The environmental health specialist is also not responsible for concealed conditions on the property or for statemecits in this repoR that may have resulted from false or misleading statemenG provided to him in the applicatioa Neither Person County nor the enviromnental health specia(ist wazrants that the septic tank system wiil continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro�permitsam O 1/95 rev.1.0 PERSON ��Ul`?TY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MO1vITORING REPORT � 3 Z<c/z � � � � �� S stem In tallation Date T e ax Map Parcel # Da of spection y YP s 0 PropertyAddress �j7� A _ 1 //'�1 ar�►e �i(!a�''e�� f.})v��,�c Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specifed in the permit aze to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks 7 Tank risers accessible, free of infiltcation and surface water diverted ? Septic tank needs pumping ? Inches of solids: Septic tank filter cleaned ? RFFI.I7ENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operating properly 7 Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? �� Inches of solids(pump/dose t�):_� Elapsed time readings 7 Counter readings ? Drawdown rate: nn YES / NO ❑�❑ ❑ � ❑ ❑ � ❑ ❑ � ❑ ►: ■ /: ■ !� ■ % ■ ►� ■ DISPOSAL FIELD: Evidence of effluent surfacing 7 Evidence of effluent ponding in trenches ? Surface water effectively diverted ? ❑ L�iv�:sier.s!sw�les groperly maintaine� ? ❑ Vegetative cover maintained ? ❑ Froiected from traffic/unauthorized uses ? ❑ Distribution devices in good condition ?❑ Field free of settled or low areas ? ❑ �N ❑N ou ar� ❑ /� �N PRESSURE DISTRIBUTION SYSTEM: Tumups/cleanouts/valves/taps intact & accessible 7 ❑ � � Pressure head properly adjusted 7 ❑/ COMPLIANCE: Compliant Non-compliant Needs Maintenance ■ r'� ■ SYS�> REMARKS � '�- �a�t� u0-� a cCPsS,'I��e. � � WQS�at� 5�+�'� � ��e. d��-� e� �°� %✓t 2XC�9t��'�C� Ai)Di 1 iONaL COM�ivTS: 1Cf�{i r Q�D�P?i �T��a`'� 5k��*� �"'t � l�D�� 2' Ju1-10-2012 09:45 AM Progress Energy Roxboro Plant 336 Applicatiun Dute: /'' b- �-2 o-p _a Amouut Paid: �Q., �OCBI�t i�: C�-�ZZ�33 �n. lmpruvement Pern�it (Site Y�:vAluatian) �2�O.UO/g300.00 (if � 60U gpd) Mobi�e T�on�ie X2Gplaccnicy�t or linildfng Addition �il5U.U0 (if sile visit rcc�uirui) Well Fermit (New/Repl�cement/Ftepair) $ � OO.00f�200.00/S7S.00 �...��, � �.i. ��'}��.�1��T�p�{��'�F 4�~ �1� � V�� V Y Y � �a � a¢na 'l�'a�i IV(ap: � Psrcel#: ra•a au�c�ab.asauavi aeu _ ilfcatfon f�r Serrrice�rR�r�`.' � � �ro � ��,,, .tlr�cu �;f Seraices �e uesteci Cunstruction Auihuriz:ftion Fee is de cndent on the �e of system . ermitted) Permit Revision 1) Anplicaut Iuformaiion: Nan2e• � SS �ir_c�' Address: k ',�n,tic�t � �� Yv,c-�.r�a 1� c = ... _ � �7 3� �. 2) Na�nc and address of c�rret►t o�+mer (iP dil'fQrent than ap}��icaut): Naine• , Address• �,�� ---- �� • -�•----- of Twxisf ��g Sc�rtic �'t'C��a'�v� l,'-�'► t�r � �� • r -� �Pe�-"t � J �' '�rJ�� bl�`-yC3�ri� Phone (home)_�cnlnr�.f '��rY'tPe.t ��Gl�'[ "1�139, (work/cell): 3'hone: 3) �'roperty Deseciption: Lot Size: N� A Subdivision: t.f � A� Lot #: �.� � Address ancUor dircctions to Properry: S�'!�� C`�r,r+�rc�t- �,�n �� M�.�-,ti,��'S �vi� � 1�� .Yes _: G}^�a �l�oes the site. contr�zn amY j�ris�iic;�ion�i r+�.ctla�its? LY'�es�'•:��:n'o�, ;..Dae.s#7ieszte�cvntai?i_azayexistingwastewaiersy.stet�s'� -�� .... ... ... . : . .. . . es t:] qo: .Is'FiiiywAs'tewFitergoingtu.l�e;�ene►�fed:on:tFi�:site;oiheri%a��ilomestics�r�nge`t �N�31' o�S�'�� Y .. . . � jr�3•� ,� �u•: �•:l§ i�c`.Bi4'c sttilijtCttcr:spprovai.Iiy ari�.iitherTiuUlic age7rcy? �1'�t�5 SL..r yzs . Q n� �. i4t�.t#tctx: si�� c;�cn7cn#s c�'C-right o#'vu,ays or� {}iis: pro�erty? �'�'�'C�►15An�5S t� t i �r►�.� (ii `ycs' is checked, pleflse J�rovide supportuig document�tian) 4} Prupn�eci Use and 'I'ype of Structurc: �Residential- � ❑ NF �nsle F �tf ily �t.e ' ence mui �be •Pbeciroocns: ��' - �� ------.... �0'�xpans � of E�ist�i� Sy m !f sio : urrenL nu�beT ofb oms; �� ❑ Repfl�r tu�14f[C�imc[iaar g Sysl -� ill : c bc a�m Rt7 ❑ ❑ nf�/01�iCh.�1 bing fix res7 ❑ cs ❑ no �J'Non-TtesldeYlti A f �'ype of business: ._C��jc.�_�,,i `nQ - �t�x� 1� ��'1'ot�l SRuflre footnge of Building: Mnxirt�um niimber of employees: � ti Mxximum niunbor of sc:xts: �� r��o� �s�eM� 5) Water Supply: Cl New weli ❑ P_xisting Well ❑ C.ptnmunity Well C�Pub ic Water i� Sprin Are fl�erc any existing wells, springs, or cxisring watcrlines on this property? � ycs 0 no . .. .. . . .. � ..Ii a�iplyivg .f�r. °lti�t�iar,%�tioii� to :C�ns�:r.net';; pl�ascii�icli�tc��r.cfcrrcd•.sysicni:.ty�c'(s-)S �� D�Conventiion.xF:.:�. E1�,A.cce��ted. ..d��Lriiiovati�e:�� t3'�liei�iative..:. C; Qtta'e��. � .:-. � '." ' '....;:�' �I�'�Any. . . ... ... ..... .......-�-----.._...---��---- ,... ....._ ... ......, . _......_.__.� I cerlif+ dFirxt �he inforrr,crlar�n proviiled tshove is cnmpl�te anc� correct. I also u►aderstaraat tyiat if'tlte ar�f'orrraatiora p�•ovided is inac�rttraie, or if'the site is subse�ue.ntly altered, or the intendec� �rse changes, nld pe.rmits cznd approvals shall bP invulid .-ti 5ignala�{,e (Owner/ �.e¢�i �2eprescntative*) '�' SuppoRing documentatian requi�ed. r%• 1Q' �,� ----� Datc • Yermi[s are v$lid for eitlrer b0 tnonilis �r $re non-eapiring �vhen accompanicd by an approvcd pis�t + A com�lete�i `�.ot Pre��nu�ntinn' f�r�n inuat acco�ypauy any appl=catinu rcquiring a sitc evniufltion. (] 011 i) Person C�Lmty Environmental Health, 325 S. Morgan St., Su�te C, Roxboro, NC 27573 (336-597-17��U) _��, s� ��..� �� ^ � � �� )E�a��a��„--„-„ ��.Il IL—��.Il�I� Applicant: � Address/Location: Improvement Permit Permit Valid for: Five Years � Non-expiring Type of Facility: �%�tD4s� New Addition _ Number of: Bedrooms J Occupants / Employees ,�/ Seats: Proposed Wastewater Syst m: Proposed Repair: � jti — vr '•�t t�✓ ,Pllr✓%p Permit Conditions: Authorized State Agent: (X) Owner or Legal Re Tax Map:� Parcel:� Subdivision Phase/Section/Lot # :.�f�" Water Supply: �� Projected Daily low: S gailons/day Type: Type: � Date: Date: �he issuance of this permit by the Health Uepartment does not guarantee the issuance of other required permits. It is the responsibility of the applicant/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 Improvement is not affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Laws aird Rules for SewaFe Tieatment and Disposal Svstems'(15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic system will continue to function satisfactorily in the future, or that the water supply will remain potable. Authorization to Construct Wastewater System See site plan and additional attachments (�. Proposed Wastewater ystem: �%C/r�Gi' `( /N� ��d''t4 � (*)TYPe �111. w Design Flow �•2 � gal./day New Repair � Expansion _ Soil LTAR: •� 0 gal./day/ftz Type of Facility: �� /�� .� .(,J¢v�1D4S-� Basement: _ Yes >C No (*) System Types Illb, Illbg, IV, and V, require periodic system inspections by the Person County Health Department. Wastewater System Requirements Tank Size: Septic Tank ��. gal. Puirip Tank /�x � gal. Grease Trap '— ga� rZ'r �Q fttrat� Drainfield: Tota( Area 37.� sq. ft. Total Length 1�{� ft. Max. Trench Depth � m. �k`� Trench Width 3 ft. Min.Soil Cover � in. Min.Trench Separation � ft. ��OyP �� Distribution: Distribution Box / Serial Distribution / Pressure Manifold � Specifications: P�r ,�t $�Qll� t�d� /� v� �tQ'��C�✓�. � Authorized State Agent: itit ' Issue Date: ! Permit Expiration Date: The system permitted is: Conventional �/Accepted / Alternative / Innovative . I accept the conditions and specifications of this permit. f�� Date• C� �� l� (X) Owner or Legal Representative: `� � Person County Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) :��,�� ,�`I � i r � � �� - �P� IE��y.�,�,,,,.,,��.�.11 ]HI��.Il� . .� - •�� ' • .. t.. .. - — _�,i� �L�. �.. -. �.-, /� � �X� . u�p P%�n� . �`1 , r� r�^ �,1, ��,., l• .. -�. , � s,.... . �� u f ,�a+�C� �IiE ��TCH Tax Map # �-� Pa:tcel # a� Sectiafl/Lot# � `� � 3 � Dat� . /VIOn i �driw( �I tN�Lt .J „ 37 , �c� i►iaK, �,�IcF �-3s' —� � � � 3s' � j. e , /'.�.� , . . -< < . � " . � ^, ,�., @ / • �� ( t�'C �" a � � dl �K ' - r, . �C; •- � � , _ �Q ' �t4'�rO�Q��a / � re vls,��Ca�� -� . � ,��e� �o� l� cf�se►�- ��.� � . o� ��e,� � ,� c �✓ � 5�,�� l��e� �� -�eS -- y� �� 1��s � tr � �Z S�� Ps �� j,s� �i �teC� ��.�,�, �,,,z 5'�t��,( Qc�i2v2 1'� �r-e� � P � �.` �� - �� 1Z ��✓��1 sa� 5'�P � t ��{ aK.� ��i s • � ;,,� c�rh S 4� (� Rc� ;-�.�e r�q�;,,.a� -� !-f � an��P�' S. � �-%�' s`� � � � --� � � , � � ��, � I�1�I�.� ��1� . -- � � �� IE;sa.-v aa-�m �eaa�aat ]HI�.m.11•EIla. wner � S 5 Tax Map: 02 S Parcel #: Date: �(3 I,ine Tap Tap (Scfl�) Tap �'lo� Line Length �iodv / f�ot # Diameier(vn) ( m) � : • (ft) 1 � . ,s— � . S 2 �. 3 4 5 6 7 8 9 10 � 7� ft of line x 65 al. er 100 ft=�� ; 100 =� gal 75% x� ga1= � gal per dose � gal per minute (gpm) = I+'low iSate Friction �ead � �� Loss: ft per 100 ft of supply line x ft of supply.line =100 = ft �� ft x 1.2 = ft of friction head �. �{�t�uA wv� Manifold Size: 3 " Force Main Size: 2" PVC �otal Dynamic �ead =� ft of Elevadon head +— ft of Pressure head +�' ft of Friction Head = � TDH Pump Requireanent• GPM @ • ft of Head Drawdown: �gal per dose : 21 gal per inch =� inch dra.wdown per dose �� :r�,a:� :� � �� ,,�� , _ � �� — �+�s��rs — . . , : . . . . , ,. � `,:'. , . ■�ci»�omoo : �-o-a-�-�. o-� � �_o-e-o-�_o-�-o-o-�_�_�_�-�-._�-�-�-o-o-�-.-. �) �I 1�) QI ��a�� .. :..� i!�!!*!!!!�.l�N!!!!!�!!i.!!��!!� � � � � • a � c : : - vc T�mlh�h� Iwi/mo�oor 9�� ' s l�ianifoid Sizr / � Tap� �old Nfa�x Na Taps off one ;�ze (Kednce b '/s ior ta � '/i" ta s '/+" taP9 Z»� 4 Z 3" g � 40+ � 21 1 �� • � �`iow er Tap Sue :Ylcu¢rial Flow GP1! ,z ,• Sclied 30 5.5 !, " Sci:ed 10 i.= 3, °' �cl:ed 80 1 � 1 ;, . �ched s0 1%.� :1 � ?_rp:is�tios jJa:e: ��d ^� Amount Paid: Receipt #: �`/ �/i 1 ��,� �� .��1�� :ax �ap: v `,_ ►•� �� Parcel#: i 4,) Cir _-o C � 7Esa�flso��a�sa�mIl 1HIo�Il�IFa �c� 1 � g3'�Application for Services Services Repuested 0 Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 �pd) 0 Mobile Home Replacement or Building Addition $150.00 (ifsite visit required) ❑ Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 ❑ Construction Authorization (Fee is dependent on the type of 0 Permit Revision $75.00 pair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: � Name: c b Address: I' 7 n S'e_.mar�ti, �.tc �`l3 � 3 . 2) Name and address of current owner (if different than applicant): Name: Address: ��M'�'_ 3) Property Description: Lot Size: Subdivision: . Address and/or directions to Property: ca nnA Phone (home): 5�`1—��7 (work/cell): ` " �p � ��` � Phone: �' C� UCi�'O� �G'�r0.f� Lot #: ❑ yes �ho Does the site contain any jurisdictional wettands? ipiyes ❑ no Does the site contain any existing wastewater systems? �`yes �d` no Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes '� l no Is the site subject to approval by any other public agency? 0. yes '�7 no Are there any easements or right of ways on this propetty? (if `yes' is checked, please provide supporting documentation) � (1x.�J � � � �� i r1 So r%-cQ � r�- —�-r �s' S�� 4) Proposed Use and Type of Structure: �Residential � ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: 0 Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? O yes ❑ no With plumbing fixtures? ❑ yes ❑ no �Non-Residential � 2 � Type of business: � �l�otal Square footage of Building � Maximum number of employees: �'��vlaximum number of seats: � , ,Q� T�,1 5) Water Supply: ❑ New well ❑ Exishn" g Well ❑ ommunity Well � Public Water � Spring-� �,`�-�� '� t�f= Are there any existing wells, springs, or existing waterlines on this property? i� yes ❑ no Please note any known ground water restrictions or sources of contamination: _�, ��- 6) I applying for �Authorization to Construct', please indicate preferred system type(s): �Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other � Any 1 certify that the informcition provided above is complete and correct. I also understand that if the information provided is inaccur te, the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. � , I o �I ignature (0 ner/ Legal Representative*) ate * Supporting documentation required. Permits are valid for either 60 months or are non-egpiring when accompanied by an approved plat. A completed `LotPreparation' form must accompany any application requiring a site evaluation. (]0/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, N�27573 (336-597-1790) ��,s� ��.�� ICe �-Ya �- � �.��.�.�.11. IF-3L � �.11 �I� Applicant; ��v'c � � Co v'/ �'� Address/Location: i . � � Permit a' r: Five Years Type of Facility: Number of Bedrooms Proposed Wastewater System: Proposed Repair: Permit Conditions: Improvement Permit Non-expiring __ New Addition / Employees / Seats: a; � Tag Map: �'�Parcel:� Subdivision Phase/Section/Lot # VVater �• Daily Flow: gailons/day Type: Type: Authorized State A�t� �at� (X) Owner or Legal Representative: Date: The issuan�e of this permit by the Health Department does not g�arantee the issuance of other required permits. It is the responsibility of the applic�ndpr�perty 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 improvemeat is aoi affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina �Luws �nd Rules tor Se►vae� Treatment and Du�osa! Svstems'(15A NCAC ]8A .19U(1). Neither Person County nor the Environmental Health Specialist warrants t6at �he septic system will c�ntinue to fanciion sat;sfa�torily in the future, or ihat ti�e water supply will remair �oiable. Authorization to Construct Wast�water System See site plan and additional attachments �_). il Proposed Wastewater ystem: /�� ►1� '� Na'� � �� Nev� Repair � Expansion J Type of Facilit-�: t.(d( `P�o � (*)Type _ Soi! LTf�R: Basement: _ Yes _ Design Flow — gal./day/ftz I�'O gal./day (*) System Typ�s Illb, Illbg, IY, and v, require periodic system inspections by the Person County Health Deprzrtment. Wastewater System Requirements � S��_u,�� ,�� G/� }'� 5 r Tank Size: Szptic Tank ! gal. Pump Tank � d � gal. rease Trap '�-'-'- gal. Drainfield: Total Area '�' sq. ft. 'fota.l Length "� ft. Trench Width — fl.. Min.Soil Cuver � in Distribution: Distribution Box / Seri I Distribution / Pressure Mani pecifications: �S� '� � � p7'�� S� �l a' k i vt -�✓� ►--Q . 5 +1 i�l1 ��ln /Dc l r�.� � �(✓l^Q . %� /1 r1 Authoriz:.d State �lgent: Max. Trench Depth --in. Min.Trench Separation -�- ft. � i� sQ�i ( I ✓� t d�� • ur �, u! a a t Issue Date: � ( ( � �'i Permit Expiration Date: �- ((- Z 2 7'he system permitted is: Conventional /Acczpted / Alternative / Innovative . I accept the co��ditions and specifcations of this permit. (X) Owner or Legal Representative: � Date: � Person County Environmental Health, 325 S Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) �� s� I�I�I��T `:.., �c��r� ]Em�aso�---.ea�.n� ]EE��e�m�l�Ils SITE PLAN ' Name � � � Tax Map# ��Parcel# � Subdivis o � � Section/LotN — Authorized State Agent Date Syslem componen(s represent approzimale contours only. The contraclor must Jlag [he system prior to beginning the installation to lnsure thal prapergrade i.s maixtained Note: An Accepted system may be used in place oja cor.venrional systen withou� permir authorization or modificarion. ��...�._�'�� r�+ cG�.-�s /�t' t l � �• S�io�l � . . �to�— � sc� �� u� a-h � t �K � �--��*��) f �� , � � �� IE �� a- � �� . �. �. Il IE�L � �.IL �I� Applicant: � �re s s �,ocati.Qn: �� L.L�l�1/.�'�!�L's::'i��<!'- � i ' � 1 � ' Tax Map ��Parcel # �� Subdivision Phase/Section/Lot # # of Bedrooms S 2e,i5 System Type (From Table Va): � Product (IIIg): ►r�lv-�. ��7kG� This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. ✓� � ��'�.�e� �' � f 2 (Authorized Agent) . (Da e) � �Q,�,�/; cl � 2c ! Z (Licensed Contractor) ate S�PC U,r r � �y��Sc.�.�-2 �d�'� Z" �►�tP �l�V. � �i� �prk-�r w\ I�tre�i � � Ja�e.. �0.iV�- � ttr�2.. � �e.. Mah;�c� � n�c. �4�� a IIII %Z`� �tZtr 7�0•G• ! r�'�.G• ro�tt�� 1 .��s � ��s�� i.�,ns�cQ �-'�' � a c�-�' I-�i.t�� i�5�-�-� d�, � �Q� � �� Scale: —�� :.- .. ; _"' _ : � � Line Len€ 3S 2 3 �- 35 � Total � 1{-p Tax Map:� Parcel #: �� Septic Tank System Checklist (Type II-I� Se tic Tank InitiaUDate State ID & Date: Capacity: Tee and filter Baffle Ver_t ,� Riser Outlet boot Perm. Marker I3i�tribstiu� D-box levels set) Seria� Pressure Manifold z� Z LPt Notes• � System Type: Pump System Checklist Contracfed Certified Operator (Type IV +Systems): Notes: , ,. i „ NOTIFIED BUILDING INSPECTIONS: ,.. . . . ,. ,,.,, ,-.� �. v� Copy of OP e-mail Date: ��, sf ��.� �� _ � � �� IL��n.�ns��nT-TM*� �n-n��.11 IE�¢��.I1.�Iia Applicant: Location: Tax Man } � Parcel # �{i Subdivision Phase/Section/Lot # # of Bedrooms . �� Operation Pern�it System Type (From Table Va): Product (IIIg): Type V& VI Expiration Date: Type V& VI Renewal Date: This system has been installed in compliance with applicable North Carolina General Statutes, Rules for Sewage Treatment and Disposal, and all conditions of the Improvement Permit and Construction Authorization. .�. (Authorized ent) � �f ��? �" �D�� (Licensed Contractor) Scale � PCFiD, rev. 12/14/12 ��c� 7'i►�OiG ,�,'��'��.��" � �/�� (Date) � �� (Date - �j�y�� z�?.Lt ��r" ��r��-�� o,�/�o. � �� G�� iG��G/l�li �' /t�i✓��°'i� ��D/'t�� Tax 1V�ap: � Parcel #: � Septic Tank System Checklist (Type II-I� System Type: Tank State ID & Date: Lapacity• �`; Tee and filter Baffle Vent Riser Outlet boot Perm. Marker Distribution D-box (levels set) Serial Pressure Manifold LPP Notes• InitiaUDate � Nitrification Lines InitiaUDate Trench Width: ft. Trench De th: in. Total Length: ft. Minimum s acing: ft. Rock de th/ uality Dams/ste downs Grrade (< .25" in 10') Cover (6" minimum) Setbacks From wells Pro erty lines Foundations/basements SurfaceWater Other: , � Pump Systerri Checklist Pum Tank InitiaUDate State ID & Date: Capacity: Riser (6" min.) NEMA 4X Box ModeL• Piggy back Iug Hard wired Alarm functioning Mounted on post Above grade (12") Conduit sealed Pressure Manifold Number of taps: Size and sch: Contracted Certified Operator (Type IV Systems): Notes: PERSON COUNTY HEALTH DEPARTMENT SUBSURFACE WASTEWATER SYSTEM MO1vITORING REPORT !� l Z � � '' 1 /Z ll � .�.5 � Date f In pection System Installati n Date Type Tax Map Parcel # !% / Property Address Instructions: Check yes or no for appropriate items and explain inspace provided for remarks and comments. If an item is not applicable, indicate by "NA". If an item is not or cannot be evaluated, indicate by "N" and explain. Note that this monitoring form is not totally inclusive for all systems. All maintenance and monitoring items specified in the permit are to be carried out. INSPECTION RESULTS COLLECTION SYSTEM: Evidence of leaks ? Tank risers accessible, free of infiltration and surface water diverted 7 Septic tank nceds pucr.ping ? inches of solids:� Septic tank filter c eaned ? EFFLUENT DOSING SYSTEM: Required pumps present & functional ? High water alarm operating properly ? Floats, valves, etc. in good condition ? Control panel & components in good condition ? Effluent free of excess solids ? Inches of solids(pump/dose tank : Elapsed time readings 7 Counter readings ? Drawdown rate: YES / NO ❑ � � ►i ■ �• ■ ■ ■ ' ❑ � ❑N� �. � ❑ � � ❑ ►'� ■ ■ ■ ' DISPOSAL FIELD: �%/� Evidence of effluent surfacing ? ❑ Evidence of effluent ponding in trenches ?❑ Surface water effectively diverted ? ❑ Diversions/swales properly maintained 7 ❑ Vegetative cover maintained 7 ❑ Protected from tr�c/unauthorized uses ? ❑ Distribution devices in good condition ? ❑ Field free of settled or low areas 7 ❑ / / / / / / / / o N�- ❑ ❑ ❑ ❑ ❑ ❑ PRESSURE DISTRIBUTION SYSTEM: Turnups/cleanouts/valves/taps intact & ��......... accessible ? ❑ � ❑ u,� Pressure head properly adjusted 7 ❑/❑ N�- COMPLIANCE: Compliant � Non-compliant ❑ ,.,_..a_ *,��:.......,,..,.e n REMARKS