A26 184�;" . -
AaQiication. Daie�: 3- / Z� Z . , . T�c ilAaa �/� h�
kmaur�Paid: /So � �v . .. _ _ . . : � �2 [.} .
Rmc2i . �vD ' • . . . ��'�
� � r✓`
�i � " . �
� '`-,.�� � ��1lE�s.��� � , � 6Z�
� � - �C ��:.���E`� .
� . . . . �� - .�-�� �r�.a� ..
• � APPLlC�t'ftON FORSEii1�S • .
.�: _«�, I I ► _��ie
1)
Z�
3)
P•radt r�ues�d — . - -Owne �+os�ve ownerr �G�I�� °� r� � �}-
Home Phone: �3� ��j , �4ddres� �U d� �( !�
Busii,ess t�hon� — 6 7) . u
Ala�e mnd �ddrass vtf c� ownec o d- �� �i ���77��
_
�� � /
Praperty �'esr.�ptlon: t.at size: %• 3r1 Tawnship�� ✓� � Sut�isiar. � La
Dir�a�s to th� ProP�Y (���9 �.�� numbers): L V' ' �
G�,, !i r.�l ��? � ✓Yl v,�.:d v �t ((..,. � � � �t �
��
v✓�� r� )�2..� I:J
�:�_.
��
Jt//.LN UN /�IUM1:.IUN SVC��L.�.��c1+i i�•ryatn�r�rv i•�'=��—��..�..��-- �i–���/ S�
'L.aT/✓�: / �1 � �i��c .s: �/� Lo7' �` �
4) Pro� Use and �n�re D��om a� e� cf �e f�w� quest�on�
a) �t� _, �9 ...� TYPe of structur� uJC �:�✓ v�dtk6 v t�epth: �
b) Nurr�er of Hed � Nutr�e.� of accupanfs or p� ie io be served: � . ._
�, �� Y�`�o_ �,� �,�s �,�,e� y��-
d) Garbage Dispasat Yes �Nc �,v° Zdh�j 6- z i-� z- •
. ,.. .
���' �Pt�Y'�fP� Privabe ���j�✓or e�ing �, Pub�� CcmtrnuiiiY � S�r� _
Are• any v+ells on adl��9 P�P�hf? Yes �No _ If yes, piease inc�ia apprmcimafie toc�ion an the s�e pisn.
6f Does the pmp�rty c�tdain ��eviowfy �ed jur�nal �? Yes _ No ✓
- PlEASE NOTE TNE FOLLOINING:
➢ A PLR�T OF T1� PRCP�TY OR S17� PL�►N A/UST BE �U81�i� WITf1 'TNl� APPi.�C.s►TiOiV:
� PROPEiiTY LlNES AN� CORNHZ3 �ftJST HE CLPARLY YARE�. -
➢. THE L�OPOS� LOCATlON OF ALL STRUCTURES �iUST HE STAI� OR AAG�. • .
9 THE Sif E 111UST BE R�IDILY A�18LE FOR �►At E4/AL[J�►T�N BY THE HE�ILTH D�!►RTN@1T ST�.
- _.�' r_���- _f��� 1��w_�1;�1 1• 1 ' ' ,r• • �� - : It � :..�r_� 1 ' • , 11= ' : _I1�• • 1 = • 'ilt' - _;� ' ��.. � �'r_
YI_ • i " . � • - • :...�'�F • �• • • �.' •I =.� I :1 1 - F• l- ti • I ti _11 � � rl l'• _ ' 1 - _ • _.. • - � I 1 - t=��l
.;t+il � = i• •' • r_.�t.• • � - • • � - s - �r_ � v 'ilt' F- - It- _-• �� � - I �_; • :.• - � _ • � 1 ' •�- t� '� -
� =.r� � .; .� ,
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��I�.��it' =�r_ :=.�r-�r.n1i- s_r
p�3D, � 10t171D1
Application Date: a`9 r � � Q O I_ c� -(� Tax Map: /`�'� b
Amount Paid: a 0 0, O D �' �Q , �'" Parcel #: I��
Recei t#• �� 3 I I I 3 �.� I-?z G� `� �
P •
�-� .���.s.�- I�I��$���
do � � � � �an-a>uv-.cana,n.�+� � ��.1.� � �
�r� 360�3 ����►
�e -� �� � z3 I`I Application for Services (Septic Systems and Wells)
�� ��
Services Re uested
0 Improvement Permit (Site Evaluation) ❑ Construction Authorization
$200.00/$300.00 (if> 600 d) (Fee is de endent on the e of system ermitted)
❑ Mobile Home Replacement or Building Addition � Permit Revision
$150.00 (if site visit re uired) $75.00
❑ Well Permit (New/Replacement/Repair) ❑ Repair of Existing Septic System
$300.00/$200.00/$75.00 No Char¢e
1) Services Requested by:
Name: ,��c � y L, M v v�►.�
Address: _ i 2 � ;r� � � P.� ��,�.Y'.� p^ ,
/�� � � .t.,� .✓F _ z� �� y
Phone #(home): 33 C, �`J y— 9 a� �
(work/cell): �'r 9-� � 1- fG a y�
2) Name and address of current owner (if different than applicant):
Name: n'1 . c � �
Address: __ � 2c� �, � , ' a � ,,�� r,��
�� b U n� ,✓� �� �t� ti
3) Property Description: Lot Size: �.• �� A�}bdivision: Lot #: r
Address and/or directions to Property: ��� c,� n•✓ � a� ,t�-�✓ v r'7 /l.✓�,
/Yl�n�'��/ �✓ LL� .�—� 2L
4) Proposed Use and Type of Structure:
Residential �/ Business/Type: Other
Number of bedrooms �/ Number of people served (seats/employees):
Basement: Yes No (with plumbing: Yes No �
Garbage disposal: Yes No
5) Water Supply:
Private Well �/ (Proposed Existing _)
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes
(please show location on site plan)
Note: A comnleted application must also include:
➢ A p[at/site plan of the property that shows property dimensions and the siZe and location of all
proposed structures.
➢ A signed copy of the `Lot Preparation' form ver�ing that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. I understand that
if the information provided is incorrect or if the site is subsequently altered, or if the intended use changes, all
permits and approvals shali become invalid.
Signature (Owner/Legal Representative): -Z /� U��. Date : Z' �"( �
10/08 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
..-..�� S f" ���$.���
. � ' � � � ����
� 71'b�717C� �CD 7taIl�1L cL 7t'a �utA.�l Jl Jl 2: �1L 11 ��
Applicant: J
Location: �
Permit Valid for Five Years
Type of Facility: �
# of Occupants ma�r S�' # of B �
Proposed Wastewater System:
Proposed Repair: C
Permit Conditions:
T�x Ma{� : F�rcel # •
Subd'ivi�sion
Ph�se Sect�ion Lot #
Improvement Permi
No Expiration
� New Addition
s Projected Daily Flow �S( O
Water Supply �_
g.p.d.
Type:
Type:
� �57����r/�_�� Date: L' l,� � 3
Owner or Legal Representativ i atur .
Authorized State A�ent��_�� /.�� • _ Date: 1-? 2-��
The issuance of this pernut by �he Health Department in does not guarantee the issuance of other pernuts. It is the responsibility of the
applicandproperty owner to in sure 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 ar the intended use changes. The Improvement Permit 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 and Rules for Sewa�e Treatment and Disposa! Svstems' (15A NCAC 18A .1900). 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.
Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (_).
Proposed/ Wastewater System: CCe d����o W r � � Q ri��� Type� Wastew er Flow �$�g.p.d.
n ion}— Soil LTAI�: � Z%� g.p.d./ ft 2
New V Repair Expa s - AI
Type of Facility: ���a� e 5 i d ('. Z Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: Ob0 gal Pump Tank: —' gal Grease Trap: gal
Drainfield: Total Area: ZD sq ft Total Length �_ ft Maximum Trench Depth �� in
o. ��
Trench Width � f Minimum Soil Cover: � in Minimum Trench Separation: � ft
Distribution: �istribution Box Serial Distribution Pressure Manifold
Specifications:
----,� �
Authorized State A�
Permit
The type of system permitted is
permit. �
Owner/Legal Representative:
Date: Z - 22 -
r
Date: Z - ZZ'(�
Alternative. I accept the specifications of the
Date: � " �%' �3'
PCHD rev. 11/10/OS
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� � SI'I'E �I�'I'�� :
Na�tne _.J� � Taz Map # � Zl� . Pa:i:ce1 � % 8� .
Sub ' ' n _ . � Section/Lot#
� ;Z'2s-/o �
� . Authorized tate Agent . � Date . �
Systesr� cumporrents siepreserst upps�na�imate �cop�torsrs o�rly: The con�i�rzctor rrarrst, f%ag the systesn prior to
bsg�nrsir�g th� instaTlution to i�sure that,pmpergmde rs mais9tained
iU�.�%� p"�tu5�}" ✓iJ'f' t✓���� — , - . _
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I���a���,.-r-r ����.IL IF���.Il�II�
Applicant: J�>t ��R�
Location: s�t r1 � �.ar C
:.�iAQ ci
Operation Permit
Tax Map � Parcel # 18�}
Subdivision
Phase/Section/Lot #
# of Bedrooms �
System Type (From Table Va): Product (IIIg): E�. �w�+-�
Type V& VI Expiration Date: h� A Type V& VI Renewal Date: A
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.
�� Q �
(Authorized Agent)
M\�JtIAE�- �w�S
(Licensed Contractor)
�pR�v�wA�
Moc��,u4�.
i�M� �i'
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Date)
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(Date)
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PCHD, rev. 12/14/12 ��M�� �v/{J�
�>lo
P
Line Length
11a`
a I�a'
3 t � a'
I ► a'
Total �'�'
Tax Map: � Parcel #: ($
Septic Tank System Checklist (Type II-I� System Type: � G
Se tic Tank InitiaUDate
State ID & Date: 5-rg- 3��} �pAs b�
I�: 3 1�
Capacity: �S � �oop
Tee and filter
Baffle
Vent
Riser
Outlet boot pp�S �, L
Perm. Marker � � b ��
Distribution
D-box (levels set) pAS l� � �
Serial �.1
Pressure Manifold a
LPP � a
Nitrification Lines InitiaUDate
Trench Width: ,3 ft. le b �3
Trench De th: 1`} in.
Total Length: ►��4 c� ft.
Minimum spacing: g ft.
Rock de th/ uali �\
Dams/ste downs �
Grade (< .25" in 10') pqs t, �, ►3
Cover (6" minimum)
Setbacks
From wells � 5��. 6�ww
Pro erty lines DAS � b l�
Foundations/basements
SurfaceWater
Other:
Notes: �,�I�.l.l. tSaT Qu6 R�' 't11'►� oY S'Epric, �iri�4L.
Pump System Checklist
Pum Tank InitiaUDate
State ID & Date:
Capacity:
Riser (6" min.)
NEMA 4X Box
Model:
Piggy back lug
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:
Tank Com oncnts InitiaVDate
Pump model:
Block (4")
Nylon retrieval ro e
Float tree and attachments
On/Off float swing: in.
Alarm float (6" se aration)
Anti-siphon hole
Check valve
Threaded union
Gate valve
Conduit sealed
Outlet sealed
A proved and secured riszr
Su I Line
Size and m.aterial: in. sch.
Length: ft.
��1; � �� ���� ��
�___. _ �' C� � �� � �
J�.�.�aa-� �� ��.��.Il IHL � �,►.11 �I�
WELL PERIVIIT (New V Repair�
Taz Map: /� 2 Parcel: ( � �{
Subdivision:
Applicant's Name: J� o�'�.
Mailing Address: /ZS uc ' �e
o G 27
Phone Numbers: 3��-�qq -qo90
Lot:
Location of Property: (`� rj� �,- � /�'f ar�ov, � �11 aw� �,�- .Sewro �� ��
Permit Conditions:
1) See attached site plan for proposed well location.
2) All applicable State and County regulations governing construction and setbacks apply.
3) Permits expire S years from the date of issue.
Other Conditions/Comments: . . . -
Permit issued by
Date• 2 � z �-/d
CERTIFICATE OF COMPLETION
New Well Inspection:
E S/Date
Grout ng: � la,'� /t3
Well Log:
Well Tag:
Pump Tag:
Air Vent:
Liner Inspection:
EH5/Date
Installer:
Depth:
Grout:
Well Abandonment:
EHS/Date
Hose Bib: Completed:
Casing Height: MethodlMaterial(s): _
Concrete Slab:
Well Driller: rne�Q, License #:
Pump Installer: License#:
Well Approved by:
Date Sample Collected:
Person County Environmental Health
325 S. Morgan St., Suite C
Roxboro, NC 27573
Date:
Date Results Mailed: '"
Phone: 336-597-1790 Fax: 336-597-7808
8/1/08
Jun 20 13 10:44a Barnette Well Drilling 336-598-9275 p.1
..•'.., SL17f.:
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ltESIDENTIAL WELL CONSTRUCTT�N RECORD
North Carolina Departmen. of Tnvironment and Natural Resources- Division of Water Qualiry
WELL CO'_�ITRACTOR CERTIFICATION # �� 7 G %�
1. L GON7T2ACTOR:
v N�U i C� C' .��2 �r�
Well Contractor (Individual) Atame
Barnette Weli ��illina Inc.
Well Coniraclor Comparry Name
611 Barnette Tinaen f�d
SVeel Address
Roxbaro NC � 27574
City or Town State Zip Code .
c 33fi � 599-�015
Area code Phone number
2 LYELL tNFQRlIAATION: ��J
WEL! COtdSTRlJCl'ION PERMfT� d [ � (�
OTHER ASSOCIATED S�ERMIi#(iEapplicabie) � �� �
g. WA7ER ZON ES (depth):
Top /SS- BoStom ��(Top Bottam
Top 2 ZA _6ottom L c ,dt(Top Bottcm
Top�vo Bottom 3oS z�,gj op Bottom
Thickness!
T. CASING: Oepth Diameter Weight Material
: 7op�_ Bottom JO� Fi_ d ys �� z� JPU c. -
; 7op / c90 Bottom 1 U 3 Ft�i fg� !-g S G1�,f V
. Top Hotiom Ft.
8_ GROUT: Depth Mate:ial Method
: Top_� �onorr� �.-C� Fc SandlCemen9 Poured
;op Bottom Fi
Top Bottorn F[
S17H V1lELL ID #(itappfica�te) 9. SCREEN: Depth Uiameter SEotSae Material
3. YYELt USE (Check Appficable Box): ResidenGal Water Supply �2].-- _ Top Soriom Ft. in. En.
DATE DRILL�O b'� �d '�-3 Top 8ottom �2. in. - in.
TIME COMPLE7ED ��� AM p PM L�� Top Bottom Fi. in. en.
4.1NELL LOCA710N: '1D. SANalGRAVEL PACK:
Depth S[ze Nfaterial
crrv: �c�� � 0 2� COUhff`/�"f'e ��-SDdil ; Tap aonom �c_
f' c7 rr���f O"� 6Y1 o R'fd N Pw � t j�t�r � S� �?B Top Boilom Ft.
(Streai Narne, tJumbers, Community, Subdivision, Lot No., Parr.el, Zip Code) � Tpp Bottottt F1.
TOPOGRAFttIG / LAND SETTING: (check approptfata box)
❑Slope ❑Vapey L�}�Ft"a'1 CiR'idge pOther
LATETUDE 36 °��' ��_` DMS OR 3X_)oOCX)cX)oOc DD
LONGI7UDE �' II Z' S S " DMS OR 7X_X7CXXX)CXXX DD
Laifiudellongftude source: � pTopographic map
f�ocation oJ.we(J musl6e shown on a USGS topa map andattached to
fhis form ifnot usfng GPSJ .
5. WELL OWNEE2
�} � �('�.�21I �11� �.�C �
Owner Name�'
i� 5 1� t.�-� I[ T' 4g !,�e �•�,� .
Street Addrass
i � �%L - z. 7S ? S4
Ciry ar Town Slate Zip Code
c 3� � 3`� ~ q� 4 c
Faea code Phone number
6. UYELL DETAILS:
a. TOTAL aEPTH:, � � O
b. DOES WEI.L REPLACE EXISTING WELL? YES ❑ iJ0 L��_
c. WATER LEVEL Be3ow Top oi Casing: Z� FT-
(!!se `+" KAbove Tap of Casing)
d TOP OF CASING IS � �T.Above Land S�rface'
•Top of casing tertninated aUar be{ew fand surfa�e may require
a varianoe tn accordance wiih 15A NCAC 2C .0118.
o. Y7ELd (gPrn)_ � • ME7HOD OF TEST BIOWfI Z011l
f. DISEt�[FECTIQN: Typo �'i�f'i Amou�t �12 CUD
f'I. DRILLING LAG
Tap Battom
0 1 �
� f �n
�/ 3 Z��
/
1
/
/
/
1
1
1.
/
/
1Z. REMARKS: �
Forma �an Descripiion
/� [�` C� iL � � R�C �
sri,vt� �4- St��4��
�l� 29. SA-��-s�o27 e
I DO HEREBY CERTIFY THA7 THFS WELL WAS CONSTRUCTED lN
ACCORDANCE W1Tti '15A NCAC 2C, WELL Ca13STRUCTI4N
STANDARDS, ANO THAT A COPY OF THIS RECORt� !-tA5 BEEN
PROVID�D TQ THE WELL OWNER. �
�„��a � ��"✓,�a,�.� - _�_:l��3
SIGNATURE OF CERTIFIED W£LL CONTRACTOR DAl"E
/,���qi/.✓r+E' '- /T,�L.�t 7T
PR[NTED NAME OF PERSQtV CONSTRUC"iIiJG THE WII.L
5ubmiE wiihin 30 days of completion to: Divis�on o€ Water Quality - Iniarmation Processing, Foan GW-1a
'i617 tlrla�l Service Center, Raleigh, NC 2T699-16'1, Phone :(919) 807-6300 Rev_ 2l09
����,s� ���.���
�..,� � � ����
I��.�a����.�:��.�.11 I�JI �.�.Il�]]�
Applicant: �Jer�y (Yl00re
Location: 5� �J L��t
n
0
� � ••
T��x Ma�� • � P�rcel � �
S�ihciivis�ioi�
FM���s�e SecMt�ion Lot y
vrfon P� ( i r �im '="n fc�- S�cfi on
`/ Improvement Permit
Permit Valid for V Five Years No Ezpiration �
Type of Facility: �� nc (c. Fclmi Iv �t,�c I 1 i nq. New Addition
# of Occupants (� � x, # of Bedrooms �_ Projected Daily Flow O
Proposed Wastewater System: u tii. ' �c:, ,r`o �cdc�cfi on
Proposed Repair: l,t, T i �� t uc�i �n
Permit Conditions:
Water Supply riJaEe c,� c JI
g.p.d.
Type:� b�
Type:
��e.(�� � ' � ► •
Owner or Legal Represe
Authorized State Agent:
Date:
Date: — C'�
The issuarice of this permit by th� Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicandproperty owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are me� This
Improvement Permit is subject to revocatlon if the site plan, plat or the intended use changes. The Lnprovement Permit is not affected
by a change in ownership of the property. Thls permit was issued in compltance with the provisions of the North Carolina `Laws and
Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900).
�' Authorization to Construct Wastewater System (Required for Building Permit)
* See site plan and additional attachments (�.
Propose Wastewater System: Pu n�Q Tn rl nVa� i J c. Type����.. Wastewater Flow �Z7g.p.d.
New � Repair Expansion _ Soil LTAR: • � g.p.d./ ft 2
Type of Facility: �j i ny � c. Fa m i ty QW c(( i n�. Basement _ Yes _ No
Wastewater System Requirements
Tank Size: Septic Tank: � gal Pump Tank: ��gal Grease Trap: IJ j�' gal
Drainfield: Total Area: g� sq ft Total Length 3�Q ft, Maximum Trench Depth .� C� in
Trench Width � ft Minimum Soil Cover: l� in Minimum Trench Separation: � ft
Distribution: Distribution Box Serial Distribution �Pressure Manifold
SpeciRcations:
Authorized State Agent: �
Permit Expirat' n Date:
The type of system permitted is
the permit.
Owner/Legal RepresentaHve:
�- mGi n i Fa I d �SP�-ci F� c�.�t'
Date: lD �C7 ` �a
����
Conventional � Innovative Alternative. I accept the specifications of
Date:
, . .� •`��.�� � � •. �.� �1.���
� � �����
��.��-��,,,�,.���.�.� ����
SifiE. ��ETCI�
Name �t,rt-Y (iloor�- �
S �
Authorized State Agent
Tag lYlap #��.�.Patcel # I_ � �
� Section/Lot#� 1
- Cn �a �-�a
� Date . �
sy� ��o�� ��� �npm�� ��u� �y. The contractor »sust, flag the system prior to
beginning the isrstallation to insure thut pr+npergrade is maintained
�ec.� a I I ,�arfs
DF 5c�-�ic �4 ca ctl
IS� �ronn Ctn�c
o F ov e-nc��
QoWcrlinc5.
Scale:�='
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P�Ii�, rev. 09/12/01
�
.� i�t�1l� S%1�C FClC ELeCn1C,3�
- S�ficac:ons
t �
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pith Suitable Sealer Ia 8oth
Fs�ds Of Ca�duic
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'7" � dctiJu ��le
� x 19ajG��a^s/c,y�lc•
,.� + �-�
_�
- Scsbeersible �
Effluent Fu� �Z�
� � �S�ngle
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�Supptq Lis�e To •P� __
� . Diarteter Sc3�eduLe 4Q PVC
. • PI�.
• . l�n RaP �i.eval F�e
.. , .
' Ga[e nalve
'Q�=eaded Unian
• . Qseck�VaLve
3/16" Syp� Brealce= F�ole
' ' z�r� st�s� � �u a�
� uacm FLoat i�.evation)
. "p�,�Q an•� Float (elecration) .
' ` "Punp OfF' Floac (ele�ration)
_�
• - I�� scrics Zozl(c� or �
• ��ui�alcfl-�. -
,� YUHP RATIHG
.
e
�1" �
� Concrete � ' ' �.
Blodc
d , .• • . , a a
� • • � • d � • • • � L � �. ' . A .
� e , , . , � . . .
�is �k�s�ll be of a st�te � Aap �._1'
1�t�. � s�ll be I�k �ts3 Q�ita .
P[JMP SYSTEM DETAII� SHEET
pump Hust Be Ra[ed To Detzner
Gallons Per Hinute
Against �O__Feet Of Tota
Dynami.c Head (TDH) -
See Folloving Shee[ For
Additionat SpecifieatioRs,
Noces, And Explanativns-
�o E�coa�rc�+5' �Ea►+K ��5� .
3C2.3�) +� S=1 ZZ��i
2z.�1-� znf� =`ac��r �Z`
m an,� �!d
� •
a�'
, • . �
' *�lock, Brick
or poured
concrete boz
*Cleanout Plue
*Note: Cleanout nlug adapted to accomodate
stand pipe to adjust pressure head, or and
additional tap may be used to accomodate a
stand pipe for pressure head adjustment
in. Threaded Tap or
saddle tap Sch. 40 PVC
�'iZ�� 5c.(,, s9D -Tc4P
(�3� ��t, o�o �aPs
sch. 80
PVC
Pressure Head to be set at � ft.
�
Taps and �
valves
Mechanical
Connector
Nitrification
lines
pRESgLTRE I�iANIFOLD DETAIL
SIDE VIEW
Support Straps
Concrete Pad, Le�•ei
END ViE�V
Support Block
Concrete Pad, L.evel
TOP VIEW
� in. Manifold
_ _ Sch. 80 PVC
From
Dosine
Tatilc
Gate Valve
To Nitrification Lines
Support Strap
ig
i
ng
� -L
p��S�PJ C�UiVTY ��1l1lRflNME�i�'�L HE.4LT1-�
Q�F�►SiE S�� ��,�C�Ei3 PLAOV Ft�R y1fEiL SYTE LA�f�Jl9T.
Tax Nap S:
� ac� P�� � � 4
Zoning
TownshiP O I� V t- I�( I�
�P��x �e r r y (Yl o� re- �.,`.
�ocxtion: � C C• �{.rM (�� .
S '
Subdlvislolr
Saetlon: �
Tvtse of Water Suppiv:
Reauirements•
Well Permit
� Individual Community Public
Site Approved by _
Grouting Approved by �
Weil Log
Well Tag
Air Vent
Hose Bib
Concrete Slab
Well Drilier:
Well Approved By: � Date•
**See Attached Site Sketch**
Wells must be 10 feet from propecty lines.
� Weils must be 100 feet from septic systems.
Welis must be �at least 25 fest from any buiiding foundation.
Other condiiions:
K�c, ��c.11 ZS� {��u5 From l�omc
� , �,�, st ���
. �o Q��.s F P
C�,,�,�� o F
. ( S' P 1 us Fro � Pa� tr Li n� s.
p � tr 11t�d
, lin�s�
I� '�ro rh P�'o Qe, rk�
PCHD, re�. 11l29/99