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A27 137The Disfricf 1-lealfh Departmenf i Orange, Person, Caswell, Chatham, Lee Counties SEPTIC TANK PERMIT Dat , � Name of owner: � � 1 � \f � lf . Name of contractor. � Address and Directions � T - � � �� ` w Person or fir�n kloing installation: `� �� ' C 1�v Address V" � � ��' �� _ _ _- -- - _ _ _ __ _ No. of persons to be served Bedrooms 1, 2, 3�4. Ac�d4t3eqal appliances to be used: Disposal, dishwasher, ashing � / � J Rec mo mended: Septic tank� � �' Nitrification line: ' �� -9 � Above recommendation based on information received and observed soil condition. Septic tank and nitrification line mus! be inspected and approved by a member of the Districi Health Department staff before any portion of the installation is covered. Date Approved: s 12- % Signe�l 1 � Sanitarian By. r Q. � f,. � r Ill.�.�-f 1 i O. David Garvin, M.D., M.P.H. District Health Officer Countersigned (Over) NOTE: Make sketch of installation showing location of house, septic tanks, privies, water supplies on adjacent property, etc. Write in measurements in order that installations may be located at later date. SUGGESTED INSTALLATION (Date ) FINAL INSTALLATION (Date � ) - (Road or Street) (Road or Street) ■■■■■■■■.■■�..■■■■■ ■■■■■■. ■■■■■■■■■.■.�■■■■�■■ ■■■r■■■ ■■r■■■■■■■r.�■■■■ ■ ■■.O■■■ �■■■�■.■■■.��■■■ ■ ■r.■ .■ ■.■■■�� ■�■��. ■ ■.. ■. ■��!!� � __��!��■ ■ ■��■ ■■��Ii�t��...�i��■■ �� ■��0[+ili�i��li��■��■ �■■■N�I��'��1��e��■■�■ ��■��EI �■��/ii�� ■��i■��11��■ ■ ■��■■ ��■��l�e■�11��■ ■ ■�� ■ Application Date: �� ^� � Amount Paid: __1�� Receipt #• � � � 7 � �r Tax Map #: /� 27 Parcel #: �' � � � �� S� I��I�� T - _ �� ma ��.a¢� APPUCATION FOR SERVICES IF THE INFORMATION IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT, FALSIFIED, CHANGED OR THE SITE IS ALTERED THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. 1) Permit requested b : (Owner/a entlprospective owner): � �-�- � • � `�� Home Phone: � — SJ Address: � . W�� S� �� Business Phone: �C O ir'a �'J � 7`i 7� 2) Name and address of current owner. _�'� � nn -P� 3) PropertyDescription: Lotsize: �•3�Township: Subdivision: Lot# Directions to the property (Including road names and n�mbers): < < - 4) Proposed Use and tructure.Description: answer each of the following questions:. a) Proposed Existing _, Type of Structure: Width: Depth: b) Number of Bedrooms: Number of occupants or peopic tu be served: c) Basement: Yes_, No Will there be plumbing in the basement? d) Garbage Disposal: Yes � No 5) Water Supply Type: PrivatQ✓ (new _ or existing�, Public� Community , Spring _ Are any wells on adjoining property? Yes_ No _ If yes, please indicate approximate location on the. site plan. 6) Does your propetty contain previously identified jurisdictional wetlands? Yes_ No_ PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAKED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for the above-described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the pe�mit shall l �� mer or Legal Representative ,�� - � " 6 0� Date PCHD, rev. 10117/01 PERSON COUNTY EAIViRONMENTAL HEALTH PLEASE SE� Ai'i'ACHED PLAN FOR WELL SiTE LAYOUT Tax NIaP S: �� 1 Parcel # I� / Zoning Township APPlicant � � � - r� I.owUon: '� 1'r ...1�f� �..� 1�1�L� K� F� C��rG �O� r� �aaa cr��s ou�r S�ct Pt�nd bt��d c�hlh �� ! ,_ Nl � Subdivislon• ��- �o� Tvpe of Water Supplv: Reauirements- Well Permit �Individuai Community Public Site Approved by Grouting Approved by �-zs �-'°'�L Weil Log �"� 7 -rd- oz Well Tag Air Vent Hose Bib Concrete Slab o��., �".� � �. ,�o � . Well Drilier: ��ANS WELL �z�u�N� — Vllell Approved By: � Date: **See Attached Site Sketch*i` Welis must be 10 feet from property lines. Weils must be 100 feet from septic systems. Weils must be �at least 25 feet from any building foundation. Other conditions: K��.�� c t 1 �oc�� ar''� s-�-�-�ic P PCHD, rev. 1't/29/99 ��. � _I�-'.�.�.�'c�� '-� � �C� ZLJ�:l� �I(`' �" -' .mia-�t5z-�m�t'n.�rn�n.��La.T(-..�n.Jl I��c.:.n.)�.�t:��n Owner: � Location: � Subdivision: Dr�160UorP OD � _�d 3 1 D�p� a�o �-��-�- � kt i� ll H 5 D� Dr�0Uo�1 � �, d ,� �v��i Lob Lot � T� �aP ��/� Parcel # �� Well Construction Distance From ncarest I'roperty Line (Minimum 10 feet) -� Distance from Septic System (Minimum GO fcct) ,i —�- Total Depth: e a$ yieId: �_ GPM Static Water Level: ��,� Water Bearinb oncs: Depth �9,� t� 11 li �` ft _ _____ li Casing: Depth: From �_ to ft. Diameter: 6 i in Type: Galvanized Stcel �✓ —�-- Weight: � �� Drive Shoe: -�-�—_ Height above Ground: _/ i— in Yes No Any problems encountered while settinb casing? _y� No If "yes" give reason: Grout: Neat: Sand/Cement t/ Concretc Annular Space Width Gravel/Ccment ___ inches Water in Aruiular Space Yes No Method of Grout: Pumped pressure Poured Materials Used: _cC Depth ___� to _�.� Ft. No. Bags Portland ccment If mixttu-e sand 1 ------- W�ibht of 1 Ba� �_ pounds � , �,ravcl� CUiilllbS� — R:lilU �(p � ID plates: Yes No 4 x 4 slab _ y�s .�o DI'1�II1L L.on i I hereby certify that tll� abovc iniormation is coiYect a�ld that tlus wcll was constructed in accordance w' set forth by the Person County Hea h Deparhnent. ith regulations Signaturc of Contractor - . Ill # � 1Datc ____� /. r� � PCHD rev O1/16/OZ Horold Winsteod prop. 0 LE� EN D #— Ekist. iron pin '�" "Iron pin set �.00. N'� w c. w��steoe r�/, � � �� Hcrold Winstead prop. � �.��c�� _ �� i.�� `�i HUGH T. WH / T T Olive Hill Twp., Person Co., N.C. NOv ,1982 Scale 1" = 100' �oo' so' o �oo' 2�• E.B.� Wood,.k. , RLS -2648, Roxboro, N�C. ��- ,�{��1��f/f1��, ``�«�oiflclhfl��II ` o. . �.••�N CARp••,.. .�`�y��'R � r Rh'F''�, ,j1� • 2 ,��y. ��N�'�� / �i� �� y/ ii .0�.44.M '��0��.�G�gTEAF�ti.��fi•� .�Q� :. : � M •`�' c2 : Q : � : = NO?At�y - _ _ � ; _ - . S�A . - - - - - - _ .� _._ _ c ' L-2648 Q : � = -o � ; _ . __ _=_ � G__-- -- . ��s._ ___ =c^_ p�JOL�� v_. � O �1� i � J� �� 11. V 2 � �� IE�..��,r,�,� ��¢�.g 7E-3[��.Il�. SIT]E SSETC�I �� . N e u i t-� �Tax�N�a.p # Ao"�l Parcel #�v? 7 u 'si N Section/LQt## � I p (� -�-7-oa Authorized. State Agent Date System components represent apprvximate contours only. The contractor must, flag the system�irior to bepinninQ the i�istallation to insure that �iroper�rade rs maintained ��,�j-�� Apptication Date• ( Z`S` � y p d �� S�' ��9 �� Amount Paid: . �1� 3 04-� `,,., ,,••• . Receipt #: ? I 3 �i � � �' � �� Cr � (IE:�mc-aa-�mm+�*�aa.ti�a..11 �1[-j[e+�s�.]L •d�. � � Lt a�ral Aaalication for Services Services � Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) 0 Mobile Home Replacement or Building Addition $150.00 (if site visit required) ❑ Well Permit (l�Tew/Replacement/Repair) $300.00/$200.00/$75.00 � on the ❑ Permit Revision Taz Map: � `� 7 Parcel#i �13�) �. Q 11 `i-o n,�e �'�' ON `'C�ucs , 01- . �U cc� of ❑ Repair of Existing Septic System Applicatioa: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: �on,. 1�alkpr Address: I j 9S2 `��„ !J A); �� a� Rc! Rnkl�nrn �UC a7S'7�l �, 2) Name and address of current owner (if different than applicant): Name: � Address: Phone (home): S9 7- p Sao �uU� �� (work/ce11): .t'9 2- l `� 7.� Phone: 3) Property Description: Lot Size: -�+ � Subdivision: Lot #: Address and/or directions to Property: ❑ yes no Does the site contain any jurisdictiona! wetlands? ❑ yes [�i� Does the site contain any existing wastewater systems? ❑ yes LWiio Is any wastewater going to be generated on the site other than domestic sewage? ❑ yes � Is the site subject to approval by any other public agency? �qes 0 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 ew Single Family Residence Maximum number of bedrooms: �_ � ❑ Expansian of Existing System If expansion: Current number of bedrooms: C7 Repair to Matfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑ yes ❑ no ❑Non-Residential Type of business: Total Square footage of Building: Maximum number of employees: Maximum number of seats: 5� Water Supply: ❑ New well LfExisting Well ❑ Community Well ❑ Public Water � Sprin Are there any existing wells, springs, or existing waterlines on this property? es O no � 6) I�f ap� lying for `Authorization to Construct', ptease indicate preferred system type(s): f9'Conventional ❑ Accepted ❑ Innovative ❑ Alternative ❑ Other ❑ Any I cert� that the information provided above is complete and correct. I also understand that if the information provided is inaccurate, or if the site is subsequently altered, or the intended use changes, all permits and approvals shall be invalid. Sigda�'ure (Owner/ Legal Representative*) * Supporting documentation required. I z S /�/ Date 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 reqairing a site evaluation. �in/111 Perenn rrnmtv F.nvirnnmPntal F-Tealth ��S C Mnraan St.. Suite C: Rnxhnrn N(` �757� (Z��_SQ7_t7om M � M N � � N \ 330.60572 14�.00874 rn ch � � � � M � 52.876967 323.645919 ssa � A27-137 Jonn Walker Pro ert p Y 127.14154 ^. --__^— --_—_ -- 216.444422 � %o S�b � f,D� V� 6 j� � �o� �� „ �•.�a � � � �i-,��+6C�� tl �L:l.i;�� -��L4�°�t.:,� 329.789187 � c.,S�l.yc �. � � �� / �� d�. �'� j �� y� � '. 6�g 03 � ti�� 3 ,�, \ ,......._...........__`._-_-. / \ � �--�� _� .389663 � �r _ �� , � �_� 216.26946 � 60 �20 240 36� 4�0 Feet L i I i I i I i Ji54��"� �� 1� ��d%' �� `_' -' - �— CC � ZL.T�T'IP �Y ' .��iC �� -�� 1F.�� sno>ns�sn.ssn.a�ra��.11 IHL��II�I�n -�� SITE PLAN Y� I� rh►� � �� L�. �� ..�� ` �-�� -�`1��.�-4� �4�� -Sc.�'�. �:a��=�."�"�� ,��i�e�`"� � �'�1� ��e�'0 �- v.i � 1.1..� v.ab'�.,�. �WSi� �1, �vv�.�" �. � ' � '� � . � ,"�.4�t��1.. �`-�� z�P. S�S�3"� .. � �� e-�� s�a�� `��., -• �`a`� - �'� � � Name -J�`�� i./F�c�\l.. Tax Map # na'�j Pazcel # ��"� Subdivision Section/Lot# ti� �Li� f� � .`��"� I�- I1 -1 Authorized State Agent Date System components repteser+t appm�dmate con[ours on/y. The conttactormust flag the systemp�or to beginning the installation to Insure that pmpergrade is maintained. � .�� .� '�2a��'� �� r...l�� `�� n �� 5 . ��, �� :� �� lJj P 7 � c ��, sf ��.� �� ?�s�-��-��:�.��.IL I�3I��.11�I� Applicant; 3�a WA1..�2 Address/Location: t3'vC '�� p- z W i.�,��qQ `�'ci � �w►�scln,r'�`i Permit Valid for: Five Years � Type of Facility: �o�Sc � Number of Bedrooms � / Occupants Proposed Wastewater System: Qi�t�P Proposed Repair: 1�uMP ��FiE�J Permit Conditions: W Improvement Permit Non-expirina New � Addition (o�'�'i` Employees / Seats: S�i►L. �1 Taz Map: �_ Parcel: 13 Subdivision Phase/Section/Lot # V4'ater Supply: ��a� ti*�'�.. Projected Daily Flow: 3b'4 gallons/day Type: .�IS.�6 Type: �S,a6 SEQt�c. S`tS�r.�M R�� '�� r U��$ So��. iF lY IS �u0 wtc.T . Authorized State Agent: i�►c:1t � (X) Owncr or Legal Representative: Date: I 2- /S-I�' _ The issuance of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of the applic�nbproperty 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 Improvemeni is noi affected by a change in ownership of the property. This permit was issued in compliance with the provisions of the North Carolina `Luws a�rd Rules for �e►vag� Treatment and Dunnsa! Svstems'(15A NCAC l8A .19U(i). N�ither Person County nor the Environmental Nealth Specialist warrants that �he septic system will continue to fanciion satisfa�torily in the future, or ihat tfie water supply will remair �ota57e. Authorization to Construct �Vast�water System See,site plan and addiiional attachn:ents � ). � Proposed Wastewater System: �i�e�� ,A�'iE.'4 �+��5`� �V (*1Typeill� Design Flow 3b'O _ gal./day New x Repair _ Expansion Soil L'Cf1R: 6. � gal./day/ft2 Type of Facilit-,�: 3�RA4�, }�O�►Sc Basement: _ Yes J No ('�) System Typ�s III6, Illbg, IY, und �; require periodic system inspections by the Ferson County Healih Department. �.�.�e �-- Wastewater System Requirements Tank Size: Septic Tank 104� gal. Pump Tank 1�� gal. Grease Trap �" gal. Urainfield: Total Area �� sq. ft. 'fotal Length 3�00 _ ft. Max. Trench Depth �8 in. Trench Width 3 ft. Miri.Soi( Cuver � in. Min:Trench Separation 9 ft. Distribution: Distribution Box / Serial Distribution__ / Pressure Manifold � Specifications: _ y L1�FS @, 90Y�T EP�4� ' S�E. �flw��LiJ '�'�c.Stiti,w� S�F.� ; O� t�at__ � _ - - �- — - fluthorizzd State tlgent: `�ERWGL �� St�R'N IssueDate: la-la-�`� Permit Expiration Date: (a -1 a. -1 `� �►C�P T'he system permitted is: Conventional /Acc2pted x/ Alternative / Innovative . I accept the cotjditions and specifications of this permit. (X) Owner or Legal Representative: Date: /2-/S /y Person Counry Environmental Health, 325 S. Morgan St, Suite C, Roxboro, NC 27573/ph: 336-597-1790 (rev 5/12) ��, sf ��..� �� ' �-�- C� � t�T1�T�I`'� I��n�aa-on��xn�.�n��.Il �3LL��.Il�I�n. Applicant: �� W A 11�� Location: � r., ,, � System Type (From Table Va): Type V& �/I Expiration Date: Operation Permit Tax Map � Parcel # 1� Subdivision Phase/Section/Lot # # of Bedrooms � Product (IIIg): !iZ �� ✓ 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. � � �� uthorized Agent) � �° C'�.�� (Licensed Contractor) Scal PCHI ip�-Z'3-(s (Date) � � 2h� �r (Date) Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� System Type: ��r ��Z Se tic Tank InitiaUDate State ID & Date: l2—z9-t G I��S 5 � �l2 Capacity: j�7"S / �'v~r� Tee and filter Baffle Vent �Riser f Outlet boot �/' Perm. Marker Distribution D-box (levels set) Seria1 Pressure Manifold LPP .. Notes: Pump System Checklist Contracted Certifed Operator (Type IV Systems): Notes: � ��i��-, .,✓4S �-.� i K s'�c� v � ��--� �,�, (. _��, sf ��.� �� ` � �^ � � �� IE��.a-� ��.��.Il IF-3C � �.Il�I� Applicant: , )04� wa�l� Location: �" 2oc7 /! /�� (,�/i n s Operation Pern�it System Type (From Table Va): Type V& VI Expiration Date: � Tax Map �O'� Parcel # � Subdivision PhaselSection/Lot # # of Bedrooms 3 , Product (IIIg): �Z �a� 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 the Improvement Permit and Construction Authorization. R� D� (Authorized Agent) � (Date) � �� (Licensed Contractor) (Date) ��i Scale � PCFID, r . 12/14/12 Line Length T..a_1 Tax Map: Parcel #: Septic Tank System Checklist (Type II-I� System Type: �`'r,S Se tic Tank InitiaUDate State ID & Date: J Z— z- � f. � � Yz ✓� Capacity: S o o v �/ Tee and filter �/ Baffle ✓' Vent f �Riser Outlet boot �/' Perm. Marker Dishibution D-box (levels set) Serial Pressure Manifold � LPP Notes: Pump System Checklist Pum Tank InitiaUDate State ID & Date: 9—//--1 5 S— z z � Ca aciry: S �v 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• �.��, � I�1�I�..� �� - � � �� IE:��-��¢.�.0 �[�.�.11,e�. Owner ��, w,ra c�t�.R_ Tax Map: A�rl Parcel #: 131 Date: �a' �-1 I�ane T'ap Tap (Scia) Tap �'low� Line I,eaagt� �odv / ff�ot # i)aameter(iin) ( m) ��. (ft) 1 i� y� ?•1 `io •o� 2 �. 3 4 � 5 � VW�C' l�v� � 7 S ��.: ��• 3ti4 �•�►. 9 10 � 3� ft of line x 65 gal, per 100 ft =�.3'� �3��'0 ; I00 =�� gal 75% x�3 gal = �`lb gai per dose 30 gai per minute (gpm) = I9ow i�ate �riction �ead g,oss: �-�8 ft per 100 ft of supply line x �$D ft of supply. line =100 = 3•��`� ft 3�`� ft x 1.2 = 3�� ft of friction head �. Manifold Size: � " Force Main Size: � " PVC Total Dynamic �ead = 1$ ft of Elevation head +�_ft of Pressure head +`�' ft of Friction Head = �� TDH Purrap Requa�eane�t: 3� GPM @�� • ft of Head Drawdown: �7� eal per dose : 21 gal per inch =$ inch drawdown per dose .,. ,r:.,a:� , � �� ,� � � - ■ `�� — :��a��t0 , , ,. j • ��. � : I I I I t' �[(�)1�� 1�) I�i (�) QI - iii�*�iiiiiiiiqii�ii�%iiiiiiii� �. _ :... , . .,_ r!!!!!!!!!!�!N!�!�!�!�l��!!!! � � � � r • :.i _ a � : : : - v: 9�cmta T�1�� i�.aim(m� ifoi3 Sizs! rt Taps Max No. Tags off one — 6�, � 40+ I z1 � si J . . . . - . " �'%w er TaP S'ii2 li�L712i"1QI �01V �'7��1 rz " Scl:ed SO .i.3 ?.:' Sched 10 7.: s, °� Scheci 80 1 � 1 ;5 ' �ched s0 I: ; �:� ,�.s� ��.� ��y- ~ ^ � � � � � .l.L 1� �a.w-a�-oaaarxa¢�aa��.� ¢'��aIl��a NEMA 47C Simplex Contml Panel 4" X 4" Presstu�e . Sloped To Sbed Water 12" Separation ` Electrical Cox�it -'s b" Covax• � .. Inlet Fmm Septic Taxtk A" SCH 40 PVC Pipe ' �� i , � . • � � Access Co.ver , •• ' e~ ' •� , , � - � r • � J • � � i � , . , •. ,. . ;r , . i.• OPening Filled With ". Aztti Siphon Hole' ♦ Portland Cement Ganut �� Cl,eck • Valve - , Higlt. Water Alarm Lev+el . (6" Separatipn� , . High Level - Pump Ox -�.,� . ;' � fiVaporLock , : � $ole _ ; Drawd � (Up H�71) - . •Law Level-Pump Ofi --r~' i'' . ;s . Pxecast Costcrete Taxtk � ;•; (Mate3ialStrengtk>3500 ., . . ., . �.`�� , : .• ..'_ T�x M�E� � - P�rcEl # Suhcilivisioi�� Ph��s�e Sc�ct�ioii Lot # Duc� SealHoth Ends Of The Conduit � 24" Minimum —i "'' ----- Threaded Gate Valv�e - -� l Zip Co Ties 4" Coxcxete 'sn s��k '-.. ;•, : . .�. Cozics�eie Risex �" Sepaxaticn � • � • •�i��' 4,,:.�-Paxtlatid Concrete Gaout . _ _: Maztu � • - : � Opening Filled With Supply ' ' portland Cement Gmut � .. Outlet To Distn'buti�on 2" SCH40PVC Pipe 1e Float Wi:es � � :. f i Floats , �; �..Rem.ovable '.:' Float Txee �. ,� r � .. .' �•°1 .. .+. 10�0 GALL�N PULW�.' TANK � °:. �4Yc�,'Q�„ �� R ��U�v �,-�r PUMP EtArING � . Pnmp Mus Be Rated To DeLiv�r �'O Gallons Per Hinute, Agaiest Feet OE Tota.l Dynaraic Hea ) .