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The Dictrict H�alth Department
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CASWELL = CHATHAM - LEE - PERSON COUNTIES
Water Supply�and Sewage Disposal
IMPROVEMENTS PERMIT No.
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Date � . - �...�'��..(
�Wf1eT: �,- �{%�} L.... e'°� t� L� +^, r a ,
Location• /
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t'� ? �.� r c..l _� n �' � � ;i _� . ;Y-�.
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Contractor: � �`-`�''`� �' � ���� � �
Water Supplp: Private .�,-�'�� Public
Sewa� ge Di;�q al acilities: No. bedrooms �� Dishwasher� Disposal,
'--'------_�
4washing machine, other automatic appliances
! .-...._...1 ,� � �e � � f /� >
�-_ . _._...s �;; : � �r k � � '
Size of tank: ; t� �� •--�.�;�_ Nitrification line: �
Other disposal facility:
Water supply and sewage disposal facilities location, installation and
protection must meet state and local regulations.
Septic tank should be pumped out every 3 to 5 years an3 shall be main-
tained by owner in such a manner as not to create a public health hazard.
Septic tank and nitrification line MUST BE INSPECTED AND AP-
PROVED BY A MEMBER OF THE DISTRICT HEALTH DEPARTMENT
STAFF BEFORE ANY PORTION OF THE�iI�S,TAI�LA ION IS COV-
ERED ANB PUT INTO USE. „ •� � f�
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Date approved: — - Signed�J� �'��-�;�? � 1•� � • �
� Sanrtaria�'
Well: .-
Sewage Disposal:
By
Cour��er-
signed
. . (O�Vner or his representative)
Certificaie of Completion , ♦(��% , �
�J ��j �� ^ �
Date Arproved: J � -�/ By: ��
Sanitarian
(OVEft)
Location of well and sewage disposal facilities sketched on back.
�
_�
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. Wrate in measurements in order that installations may be located
at later datef Note location of water supplies on adjacent lots. .
ci>�,^��-�' cz� � � I� �--
Appiicatton Date: G'�'��'
Amount Paid• ���
Re�� ' a �'3—
Tax Ma #: � 7
����: a 3 I
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APPLlCA710N FOR SERVICES
�
1) Permit requestsd by: (Ownedagent/prospective owner): �'h n e Of f��► � I� � U f� ea M S
Home Phone: 5�9'%'3 9 Address;i
8usiness Phone: 59 - S /! � � '
2) Name and address of curnent owne� h I ��7�G �► ���r
` Z
x nr v C�
3) Property Description: Lot size: ��4 � Township: Subdivision: Lot #
Directions to the property (Induding road names and numbers): SQ � it!( a �
5"7 N -'�
4j proposed Use and Structure Description: answer each of the following questions:
.... ' a) Proposed _, Existing ✓, Type of Structure: a R P„-�9 ���s� s Width: Depth:
��' b) Number of Bedrooms:' - Number of occupants or people to be served: �
����) Basemer�t: Yes��No _ Will there be plumbing i� the basemenY? _
' . d) 6arbage Oisposal: `1`es . No �
5) Water Supply Type: Prlvate ✓ew _ or existing_�, Public , Community . Spring _
� Are any welis on adjoining prope�ty? Yes No _ ff yes, please indicate approximate locatlori on the
'site plan.
6) Does your properly car�in previously identifled jurisdictional wetlands? Yes_ No_
PLEASE NOTE THE FOLLOWING:
➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITfED VIIlTH THIS APPLICATION.
➢ PROPERTY I,INES AND CORNERS MUST BE CLEARLY MARI�D. -, .
➢ THE PRaPOSED LOCATION OF ALL STRUCTURES MUST BE STAf�D OR FLAGGED.
➢ THE SITE MUSfi BE RE�►DILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTAAENT
STAFF. ' �
I hereby make appiication.to #he Person County Health Departrnent for a site evaluation for the on-site sewage disposal
system for the above-described property. I agree that the contents of this appiication are true and represent the maximum
faciiiiies to be piaced on the property. I understand ifi the site is aitered or the intended use ct�anges, the permit shaU
owner or tegai t�epresetnawe
.� S_ p �
Date
pCND. rev. 06l27102
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. Tax Map �2� Parcel # 23L_ Tov�nship: f�„��.-o
Applicant: h; � ^.,Q ��
Subdivision: � � „+ �
'�yp� mg�T���' ��pp�y: ,�,�individual
lteqa�ia�ennen�:
Site Approved By: C�S (o- -p
Grouting Approved By: - -�
Well Lng. P_�k �1I i�J I��
Pump Tag: .
Well Tag:
Air Vent: � �
I3ose Bi�• �
Casing Height• �
Concrete Slab• � �
Well Driller: L�rS
�iTell Approved by;
�a**�ee.��ched 5ite 3l��tch*�*�
Commnnity Public
Liner.
7nsta.11ed by: _
Depth set• _
Grouted: �
Dafe:
Water Sample:
Wells must be 10 feet from property lines�
�lells mu,9t be 100 feet from septic systems.
. ells must be at least 25 fee# from any buiiding foundation.
Date:,
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Owner: �
Location:
Subdivision:
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Gront Log
Tax Map �� Parcel # „��[
Lot #
Well Constru on
Distancc From ncarest Property Line (Minimum' 2� feet)
Disfanca &om Septic System (Minimum 60 fg e�t)
Total Depth: ��ft Yield: �� GPM Staric Water Level: _
Water Bearing Zones: Depth �j'.� ft,� ft ft ft
fl
Casing: '
Depth: From �� to �,�_ f�, Diametcr: G� in
Type: Galvanized Steal
Weight:l�� Thictmess: �'� Height above Ground: ^L'� in
Drive Shae: t/ Yes � Any problems encountered while setting casing7 _Yes � No
If "yes" give resson:
Grout: � /
Neat: Sand/Cement !/ Concrete GraveUCement
Annulaz Space Width _� inches Water in Annular Space Yes `l�o
Method of Grout: Pumped Pressure vF6ured Dopth to
Materials Ussd:
Na. Bags Poriland cement Weight of 1 Bag � Paunds
If mixture (sand, gravel, cuttings) — Rstio �to ��
ID plates: _ Yes _ No 4 x 4 slab J�ea _ No
Llner:
Depth:
Date Installed:
DrlIIing Log
From To Formsttion
�i �-
Ft.
Grout: Installed by:
Location Drawing
I hereby certify that the abave infottnation is correct and that thie well was constructed in accordance with reguiations set forih
by the Person County Health D/��� n (1 �
\1
Signature of Contractor
Pump Installativn Contractor:
Pump Depth:
Pump Make & Madel: _
ID � D 3 nate r7 �,��,a c
Pump Installment
5tate Registration Numher: _
R Static Water Lcvcl: ft
Pump Size and Rating: �_ hp gpm
I hereby certify that this pump was installed and the well head compisted according to the Person County Well Rules in effect
on this date and that a copy of this record has becn provided to the well ovmer.
Pump Installer SiQnature Date: PCHD rev O1/27iO4
Application Date: I ��z I-D %
Amount Paid: I a�. D0
Receipt#: IO 3�� Z
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3� 7 �� :�-�..���n: ���..�»-��,�«��.7► ��—�.�,.�� �:�E�.
Application for Services
(Sentic Svstems and Wells)
Services
❑ Improvement Permit (Site Evaluation)
$200.00/$300.00 (if> 600 gpd)
❑ Mobile Home Replacement or Building Addition
$150.00 (if site visit re uired)
Well Permit (Ne acement)
$225.00/ 125.00
Tax Map: � 02 7
Parcel #: 02 3 T
❑ Construction Authorization
(Fee is dependent on the type of sys
❑ Permit Revision
$75.00
❑ Repair of Ezisting Septic System
No Charge
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Important: If the information in the application for an Improvement Permit is incorrect, falsified, or th"e site is altered, then the
ImnrovementPermit and theAuthorization to Construct shall beco�ne inva[id.
1) Services Re u sted y; S
Name: �
Address: 7 S 2 l 0
fs �c �u+'d . C .
Phone #(home): S 4%'' 3�/ Y�
(work/cell): S l�� — �1
2)Name and address of current owner (if different than applicant):
Name:
Address• �, i., D
3) Property Description: Lot Size: Z�Subdivision:
Address andlor directions to Property: �{a .S'? N'.
4) Proposed Use and Type of Structure:
Residential ) Business/Type: Other
Number of bedrooms �/ Number of people served (seats/employees):
Basement: Yes _ No _( rth plumbing: Yes _ No � Garbage disposal: Yes _ No _
Approximate size of building foundation: Length Width
5) Water Supply: -
Private Well lProposed Existing _�
Community Well: Public Water System:
Are there wells on the adjoining properties? No Yes (please show location on site plan)
Note: A completed apnlication must also include:
➢ A plat/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 verifying that the property is ready to be evaluated.
I am submitting this application to request services from the Person County Health Department. The information
provided is accurate. I understand that if any site is alt red he intended use changes, all permits shall become
invalid.
er/Le al Re resentative : � Date: !`rZ '�d 7
Si�nature (�wn g p )
11/07 Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
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Tax Map 27 Parc$1 # 23 ► �.. Townslup:
�11C8IIf: Pi'1 �� � 1� QQm S
Subdivision. Lot # .
Location:_ S�7 h( � D�n �L u � 2� 29
�ype of �ater�5t�pp�y: _✓Individual _ Community Public
Ite�uir�ment�:
Site Approved By: TS
Grouting ApPrflved By / , �j
Well Log: � �
Pump Tag: . .
Weil Tag � �
Air Vent: ` �
Hose Bib: �
Casing Heigh� �
�oncrete Slab: � � � ' �
Well Driller- �v � ,� �
Well Approved by:
*�**See.At�ached �it� S�Cetci�****
Liner:
�Installed by: _
Depth set: _
Grouted:
Date:
�i�liater Sample:
Wells must be 10 feet from pmperty lines.
Wells must be 100 feet from septic systems,
Wells must be at least 25 feet from any building foundation.
Other canditions:
Date:
PCHC rev 01 /27IQ4
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Name � �• � ��'h�
Sub ' 'sion
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Autho�tzed te Agent
SI'I'E ���I'CH
Tag Map # �� � Pa:rcel # Z��
Sectian/Lot#
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Date
System cum�onenis re�iresent a�prnacirsaate�contorsrs only: The contmctor must, fTiag tlae .►�ste�lbrior ta
beginning $fie iristalla�'an to insrare th�tpm�e'rgrade is mai9atasn�d
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�cale: ►� �a. �o ��. (�.,`
P�I�[D, rev. 04/12/01
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� �n►•• eas-a7►�ra.�rrs�ss.��•�1 �'�r•a►1���s. � � �••
Gr'Ort LO�
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�wr�cr: . .. _ ..��1..s_.,� �� -L�.���-�»---�—�--�-..r _ _
Location: _.� % -�-...,.__. ...._.,__.._._....�-.---.---�----�-�------.�.._.._---
4ubdi�nNon. _ _ __.,.� ....�.._ __._._ Lo4 M . -
Wiii C�rab'setl�s
Dt�tance Frorn ncarest Pro'P�rt'Y ��sse (Mintmum l0 f� `�
Dutant� t�an Stptic Systsn► {Miai.�raum 60 )
'i'otsi Tkpch: „� �-� ._ R Yie1d; _�,�_____�PM Ststic W��r Lavel: _�..r R
Wat�tr Hes�iny Zones� �1� c�CL�. ft......r.� �...,._.....r.. ...�.,-.--.—
(,`aie;: �, �
Deyth: F:am _.._...C2 - - � �.-.- �. De�meoer: � r
Type: Cialvsttiud Stmsl �/'
Wai�ht: f,,� _ 'Tluclatisa: .J.�, iia1tbt aboYs A3ccoue�l: ��
Ik�ve 3hoc: _ r�Yoa _...._. Nu �y probte� �n+��d whils sstci�� cariss�? �,_,Y�e ._.._ ?�o
[f "Ya" �ve rc�wn • �_. _.,..,_._........._._ ..__. � ._.....,._.. �
Grwt:
Ha.c� �d�c�� ✓ c.�tc ,�,�, t�a.►.vc:��c _ �.... � ,�i
Aruialar 9piu:c Width _�._�._„_ r:+c+�ww W:ut in Atvnuiar 3psce Yes _:'�v
M�t!►nd �t C�rout: Ps�rrr�,ed ___._ Pr�oNuie ._...,,,,_ pou�d `- i�apth W..L2.,_ t� �� Ft.
Mu�r4aM U�.i:
tdo. Bs� Poct4nd cement e_ _____ Wei=ht �f 1 Hs� „�� �ovndo
I� mixturt twad. �rsvet, cutlin�s} -� Ratio _r�. w�
ID plaus: ��ei �, No s x 4 okb „� e� _,_.. Na
Ussr:
�� _..� �_ Uste tnrcatl�: C�rroue: .�,.._.......r_ ln�csllc� by. .,�....,�,.__.�...
D�Wing La�
Lacartbe Dr�tw�t��
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' I hcrcby ccrt3lj� that thc sbovc ir.fi.�rrnrraan is corraot and Mat thi� we11 w�� rans�ueud rn �c,eardanee anth re�utrtione �r facs.
by tlse Per�aa Counry Htstth Ikparprx�t. ,
9���t�ure ot CoMtr�ctvr ,-��.�����__....��....`2? � 1D A� _,.�,b� a DatQ �.^...�.,.�.5� %
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piu�rp 1dsWlmuc
Pump lt�st�llnti�rn i;untrsctc�t. _ Stsie Rssi�tr�csun lvumt�ar. _,_
Pump t�pth: ti Stotic Watar Lav�rl.�"...� _ w R _.__.�___ .... .__ �_.. .
Pump M� & Mod�l. �.� ... ... _. ______......_... Pump 5iu �nd Rac.�n�� . . ...hp ._,_..._...._... ft65m
1 hercby ccrtity thst �hi� pump w�e �natajtsd aisd tbe wcll h�! compisted acaordin� to tbe Ycr�an C:.ounsy 1We11 Aulca �n r. fteci
on 'hi� 3ste and th�t a..opy of thrs recrn'd h�e Occn pmvided ta ths we11 oar�'.
poeno iwa/�iler Sl�aai�r�
m
Date:
PC'�iD Tev 41tZ' '°i�+
Application Date: L�"� �") 3 ��� ��' ��Q ���� Tax Map: 2'I
AmountPaid: � .._,..�'��- ���-��� Parce(#: J /
Receipt #:
1E3:�cz-ynn-�cnanmrs�:intiau..11 ).Hla�.s.11.tiln.
tion for Services
Services
❑ 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
❑ Construction Authorization
(Fee is dependent on the type of
❑ Permit Revision
$75.00
pair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information: �� �
Name: 1�etinn� �2c�m�
Address: aL7�� �j�,,.,ora c`Z�
f�x horo i\ C �`15% `�
2) Name and address of current owner (if different than applicant):
Name: l�¢�o� C�b � �
Address:
3) Property Description: Lot Size: .2 %�C, Subdivision:
Address and/or directions to Property:
Phone (home): �3 � • S`1 i� 7SS ►
(wor�/cell): � l D • $1 �{ • 735�"
Phone:
Lot #:
❑ yes o Does the site contain any jurisdictional wetlands?
❑ yes F�-n� Does the site contain any existing wastewater systems?
❑ yes �a Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes .�-t��s 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 documenta:ion)
4) Proposed Use and Type of Structure:
❑Residential
.��e�v Single Family Residence Maximum number of bedrooms: � L
❑ Expansion of Existing System If expansion: Current number of bedrooms: /'
❑ Repair to Ma(functioning System Will there be a basement? C�-y�5 � no With plumbing fixtures? es ❑ no
❑Non-Residential =
Type of business: ��-"`4—e— Total Square footage of Bui(ding:
Maximum number of employees: / Maximum numb of seats: /
5) Water Supply: ❑ Ne�v well ❑ Existing Well ❑ Community Well Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
Coriventional ❑ Accepted ❑ Innovative ❑ Altemative ❑ Other ❑ Any
I cert� that the informatiori provided above is complete and correct. I also understand that if the information provided is
inaccurate, or if the site is subsequently alteYed, or the intended use changes, all permits and approvals shall be invalid.
Representative*)
* Supporting documentation required.
�-�,_f
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 requiring a site evaluation.
(10/I 1} Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790)
Application Date: � f'�' r i1 � ��'� ��
Amount Paid: � ��
Receipt #: '713� � \
Ckh� 395�
❑ 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)
$300.00/$200.00/$75.00
��� ) f �����1 V Tax Map: ��`1
.r,: "� Parcel#: .2� 1
� ���TI�T�C�
�!.�mv nn'aDmivaaa�.an9;au.� ����s..��.iEn.
Services
for Services
D Construction Authorization
(Fee is dependent on the type of system permitted)
❑ Permit Revision
$75.00
�—Repair of Existing Septic System
Application: No Charge/ CA $150.00 or $300.00
1) Applicant Information•n
Name: � �.�, t��<< m5 Phone (home):
Address: 2`7 � �e,-,no ��— � (work/cell): _
2) Name and address of current owner (if different than applicant): p��
Name: "n QGn n � �� ��S Phone: 9 1 b • $ �� • 7 � S � �� "'\,-
Address: � U ( _ ,��
xba�c, � � �,75 �`�
3) Property Description: Lot Size: C�� Subdivision:
Address and/or directions to Property:
Lot #:
❑ yes 8'no. Does the site contain any jurisdictional wetlands?
❑ yes a" o� Does the site contain any existing wastewater systems?
❑ yes BTio Is any wastewater going to be generated on the site other than domestic sewage?
❑ yes �io � Is the site subject to approval by any other public agency?
❑ yes � 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 Maximum number of bedrooms: �
❑ Expansion of Existing System If expansion: Current number of bedrooms: ��
❑ Repair to Malfunctioning System Will there be a basement? �❑ no With plumbing fixtures? �d'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 H'Existing Well ❑ Community Well ❑ Public Water ❑ Spring
Are there any existing wells, springs, or existing waterlines on this properiy? ❑ yes � no
6) If applying for `Authorization to Construct', please indicate preferred system type(s):
�0'C`onventional ❑ 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.
-�. -�J.-v`�
Signature (Owner/ Legal Representative*)
* Supporting documentation required.
_�I�4• t�
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 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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Applicant; �
Address/Location:
Tag Map: A►a`l Parcel: a31
Subdivision
Phase/Section/Lot #
Improvement Permit �
Permit Valid for: Five Years �(, _ Non-expiring
Type of Facility: �Sz'c New Addition V4'ater Supply: ���T. Wti-v�-
Number of: Bedrooms / Occupants / Employees / Seats: Projected Daily Flow: gallons/day
Proposed Wastewater System: Type:
Proposed Repair: �tW�,=p3tc'X� Type: '�. 6
Permit Conditions: '�` �4f'���.�`'
Authorized State Agent: ��'RF 1C�L. �• �+(T�, Date: �1►\Q � 1�
(X) Owncr or Legal Representative: Date: % 2-!�_
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The issuan�e of this permit by the Health Department does not guarantee the issuance of other required permits. It is the responsibility of
the applic�ndproperty 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 not affected
by a change in ownership of the property. This permit was issued in compliance with the provisions of the l�iorth Carolina `Luws
and Rules for Se►va�� Treatment and Disnnsal Svstems'(15A I�iCAC 18A .i9U(1). Neither Person County nor the Environmentat
Health Speciatist ivarrants that :he septic system will continue to f�nciian satisfa�torily in the futnre, or ihat the water supply wi�l
remair pota5le.
Authorization to Construct Waste�vater �ystem
See site plan and additional attachments ("_).
�
Proposed Wastewater System: Ac.cr,�S� (*)Type IZf 6 Design Flow �' _ gal./day
Nev� Repair x Expansion Soil LTfiR: `—' gal./day/ft2
Type of Facilit-�: ��pv,S�, (.CRt�i� Bsse;nent: � Yes _ No
('�) Syslem Types Illb, IIIbg, li�, and v, require periorlic system inspections by th_e Ferson County Health Department.
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Wastewater System Requirements
Tank Size: Septic Tank E�sn.�� gal.
Drainfield: Total Area `�� sq. ft.
Trench Width � ft.
Pump Tank � gal
'fotal Length Zy0 _ ft.
Min.Soil Cuver �o in.
Grease Trap � gal.
Max. Trench Depth Z.L} in.
Min:Trench Separation i ft.
Distribution: Distribution Box / Serial Distribution J�. / Pressure Manifold
Specifications: _ 5�� S�� SY�r�T� �_.1, o t� S�t,v�_ ov�l. A�l�. Pa��. 4�
S�,�c. S�S t-�
Authoriz:.d State Agent: �W(ttc�, !� - St�� Issue Date: 1 1�l �`i
Permit Expiration Date: 1� ia 1
7'he system permitted is: Conventional /Accepted �/ Alternative / Innovative . I accept the co�iditions
and specifications of this permit.
{X) Owner or Legal Representative: � Date: � r`' S 2���
Person Counry Environmental Health, 32s S. Morgan St, Suite C, Roxboro, NC' 27573/ph: 336-597-1790 (rev 5/12)
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SITE PLAN
Naine �AT�E F�R� Tax Map #�h Patcel # a3�
Subdivision Section/Lot
1.'1�i�1cx. �4. S�m�c ��V j�
Authodzed State Agent Date
System compaaents represent approadmare contours only. The cantracmrmusttlag t6e systempdot to begrruiing the insrallntion ro
insure t6atpmpugrade is maintained.
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Applicant: �Ea�J,� Y.��
Lacation: Hw�c 5`1 7�st �-#1 a
Tag Map Aa`l Parcel # a3l
Subdivision
Phase/Section/Lot #
# of Bedrooms � 1�
���2�°at1011 �� t �` �4-a��t.�
System Type (From Table Va): '�il �, Product (IIIg): �"L i-���
Type V& VI Expiration Date: •- Type V& Vi Renewal Date: --�
This system has been installed in compliance with applicable North �arolina General Statutes, Rules for
Sewage Treatment and IDisp�sal, and all conditians of the ImProvament Pe�mzt and Constr ction
Authorization. S
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(.4utharized Agent)
J�cSs�. ��4�.EC'
{Licensed Contractor)
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Scale 1�%S
PC�ID, rev. 12/14/12
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(Date)
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ot �c�s� ��� -
Line Length
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Taz Map: �2'I Parcel #: a31
Septic Tank System Checklist (Type II-IV) System Type: 1"�S Co
Sepiic Tank InitiaUDate
State ID & Date:
Capacity:
Tee and filter
Baffle
Vent '
�Riser
Outlet boot
Perm. Marker
DistributiQn
D-box (levels set)
Serial
Pressure Manifold �
LPP
Notes•
' Nitrification Lines InitiaUDate
Trench tNid�h: �3 ft. �p,s u ��4-
Trench De th: Z,y in.
Total Length: �a ft.
Minimum s acing: ft. �
Rock de th/ uatity --
Dams/ste downs oa�s �� ��-
Grade < .25" in 10')
Cover 6" minimum}
Setbacks
From wells �� �a ��-
Pro erty lines
Foundationstbasements
SurfaceWater
Other:
P�mp System Checklist
Pum Tank IniiiaUData
State ID & Date:
Ca acity:
Riser (6" min.)
NEMA 4X Bog
Model:
Piggy back plug
Hard wired
A1arm fi.uictioning
Mounted on ost
Above grade (12")
Conduii sealed
Pres�ur� Manifold �!
Nurrtber oF taps�_�. --- -
Size and sch:
Contracted Certified Operator (Type IV Systems):
Notes•
Tank Co� onents InitiaUDat�
Puiup model:
Block (4")
Nylon retrie�al ro e
Float tree and attachments
On/Off t�oat swing: in. j
Alarm float (6" se ara�o�)
Anti-si hon nole
Check valtre
Threaded ur.ion
Gate valve ~
Conduit sealed
Outlet sealed
A proved and secured riser
Su 1 � Line �
Size and n�aterial: in. sch. j
Length: R ft.