A27 26OLQ l�LIO�.:tld �T(�TE 1 d-�J`�1 E�
, - r-" ��rson County Health Department
Weli Permit
Date: �> -14 • R� This Permit Voi� After 5 Years �o�"�'
Owner � n t� n iQ � r�.�� -�n_��' SR# ��
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�/vYM '� '/ (V ov► I C►-=1" 1�:��Q Ct� w. h2rrh �"( en.ers.y Uv �
Subdivision Name: ' # �
Drilling Contractor. �
WELL CONSTRUCI'ION �
Distance from Nearest Property Line Distance from Source of �''
Pollution �
Total Dep� Ft Yield:�_ GPM Static Water Level Ft �
Water Bearing Zones: De� FG FG Ft.
Casing: Depth: Froms�_to Ft. Diameter: Inches ►�
TYPE: Steel Galvanized Steel ✓ �'
If Steel, does owner approve: No �
Weight: Thickness:�_ Height Above Ground: Inches '�
Drive Shoe: Yes No I�
Were Problems Encountered in Setting the Casing? Yes No
If "yes" give reason:
Grour. Type: Neat S d/Cement Concrete
Annular Space Width Inches
Water in Armulaz Space: Yes No
Method: Pumped� Pres�,yre�_ Poured �
Depth: From to �—�� Ft.
Materials Used: No. Bags Portland Cement Weight of 1 bag_ibs.
If mixture (sand, gravel, cuttings) - Ratio: to
ID Plates: Yes � No
4 x 4 slab Yes�No
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNfY H T EPA ME .
� 4 (5 q
Si ture of Contra or Date
�//��4
anitarian Si nat e Date Issued
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
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. Write in measurements in order that installations may be
l�cated at later date. Note location of water supplies on adjacent lots.
,� � � � .
(1) ' �2�
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; Person Count
y Health Department
Sewage System Improvements Permit
Date: ��g' � This Perrr►it Void After 5 Years Permit # E�" � U`� d
Owner• 4Y�-h !��—� ! C��C� F' r� s� "S #,���
Location/�rectiorls: �g ' { r'�'`"�" '
Y-w w� S '? f .-e '" ��� .-,�
Subdivision Name: Lot #
Lot Size: �� ��' YPS Type of Dwelling:
Water Supply: �vate: —� Public: Community:
Bedrooms: Garbage Disposal� o � ���.:, _
Bascment � Basement tur
INFORMATION CERTIFIED B
Environmental Health Specialist: o er or reP u�e
REPAIR: REEVALUATION: G��
Size of Septic Tank: ��U� �allons Size of Pum
Nitrification Line: �
Depth of Stone: 12 inches
N1a�c Depth of Trenches:
Altemative System: Conv. Pump LPP Pump
Remarks:
--------------------------
Date Well Approved: Well should be 100 f� from any sewer system
BY Environmental Health Specialist
Date a¢� S��e p rov : . -- '7 � G U
$y I aA _ Envirnnmenta Hea_th Snecialist
TE OF COMPLETION
Contractor.
Sewage System location, installation, and protection must meet state and local
regulations. Septic tank should be pumped out every 3 to 5 years and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nisification line must be inspected and approved by a member of the Person County
Heaith Depaztrnent before any portion of the installation is covered and put into use. If
the site plans or intended use change this pemut is subject to revocation.
(G.S. 130 A-335F)
I.ocation of sewage disposal sewage system sketched on back.
(OVER)
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Aa�lleation• Dats: � — �i `
,�mour�Paid: . •••• ._
R�i . . . .
, . Tax flA�a ; #k
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3) Progerty D'asr.�iptlon: Lot siza: Taw�hip: �e �^
Dir�tiona io th� [�P�Y ���9 raad. �� numbers): _
. � /h� �� i{D ��K-Tll �Cli'1 CI�JI�
�a� �,To-�
�. �uS� .
4) Propoaed tlae and �t�ctu�n D�ser�tlom ans�" �ch af tha foilowfig ques�on� •
a) Pro�msed _. � E�ing �✓TYpe af Strudur� � Widtt�. i�epit�:
b) Nurr�6er of fledcaom� ,� Numb� of accupanfs ar p�ple tio be servec� ?� ' , ._
c) Ba�nen� Yes _„ No 1NN thexe be p4unbing tn the basement?
d) Gerb�e ��t Yes ,� Na �, .
� w�' �'ijltta: Prfirabe _(t�► ._ ar ex�ng ✓�, Pub�c_, CorturuusitY _, SP�9 _.
Are•any urd� cn adjoinm9 P��1? Yes _ No _ tfyes, �e i�e aQ�e l�an cn Qre s�e �n.
Bj Does the proprcty � phevioc�y �d jut�ai �� Yes _ No �
PLEA9E NOTE THE FOLLOWING: . . , � -
'➢ A PI„I�T �'i't� PROP�TY OR Sif'E PL�1N �19'i' BE �lBYtl'iEfl WITEi THiS Ai'PLiCA►TiON:
� i�P�iiTY W�IE� AND CORII�RS �JST BE CLEI�RLYliAR�. .
➢. T'HE 2ROP09� LOCATlt�N OF ALL 9iTRUCTURES 9WST HE STAIt� OR PiAGG�. • �
� n� srrEerusr� �►nu.v ��et.� FORaAt Evaw�►-rroN e�r � t�►�n� D��►�Tee�r srar�,
t• h�re� m�ae a�plic�an to the PersoR Cau� H�Ifh Departrnent fioc a s�e �+►aivaticn t5r the oh-siie �rage dtspasal
sY�m ior the above-de�bed property. 1 agree that the conbents af this appQc�ttoa at�e true and repre�nt the ma�num
f�ities tc be on the prope . 1 under�and i� the s�e is ai�ered or the inbended u� changes, the permii shait
�� � � : �� -�� .
o� �e Datis
_ pC�.�p� tat►.1Qt17/01
�,o�lication �at2: g ���� 3
Amount Paid: �
�e�iot #:
iax t�ilap �• �� �
�arcQf �:
��� .�� I�I�I�.� ��
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�Gaa.�a-.�ss-�-�--� ma�.�-m.Il. 77C��.m.I1�1ia.
�4�PLfCATiOM F�R SERVIC�S
I� Ti-IE IMF�F�MAT101V IR� TD-IE APPLIC�►TlORI �OR AN iMP�ROVENfEfVT PER�flIT IS IMCORRECT, Fd�LStFiED, �
CHAfVG�D OR THE SITE IS ALTERED TFiEit� THE IMPf2OVEMEAiT PERi1�IT AAID ,4UTH�RlZ�.T10N TO
CQIVSTR4JCT SF1AL�. BECaME INVALID. � �0-S'��
1) Peranit r�quesied by: (Owner/agen�fprospective owner : /� �� G �S
Home Phone: _Sg9— .SgF `� Address: oN �
BusinessPhone:_��,g.93. . o G�-.7S?�
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Name anca address of.caa�nt awner: z- a e�
J � �N
es
._/ w� `. ll ���_ _ _ .
3) Prapecty Descri�
Directions to the
�) Pro�aosed Use arad Struc#ure Description; answer each of the following questions:
a) Proposed , Existing , Type of Structure: Width: � Depth:_
b) Number of Bedrooms: � Number of occupants or people�to be served: �
c) Basement: Yes No Witl there be plumbing in the basement?
d) Garbage Dispasal: Y�s , No �
5) 4lVat�r Supply iy�e: Private �(new _ or existing`�, Public , Community , Spring _
, Are any welis on adjoining property? Yes_' No _ If yes, please indicate approximate tocation on the
� site plan.
6) Does your property contain previously identifiec� jurisdictional wetlands? Yes_ No�
PLEASE PlOTE THE F�LLOWING:
➢ A PL�►T OF THE PI�OPERTY OR S1TE PLl��►IV MUST BE S19BMl'y'TED 1NIT'H THIS APPl.1CAT10N.
9 PR�PERTY Ll1VES AND CORidERS 118UST BE CLE�►►RLY MAR�D.
9"9"HE P4i�POSED L�CATIOId OF AL�L STRUCTURES MUST BE.STA�fED OR F'LAGGED.
➢ l'iiE SiTE 11�UST BE 92EADILY ACCESSIBLE F�R B�N EVALUATiOPI BY THE 9iE�►LTN DE��►Ri'NiEi�T
STAFF. •
I hereby make application to the Person County Health Department for a siie 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 ma;.imum
facilities to be placed on the property. I understand if the site is altefed or the intended use changes, ttie permit shall
�'-l� =4�
Date
PCND, rev. 06/27/02
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Applicant:
Location:
Pl l c, Z� C,(CG� �OOSC
T��x M�a� � . Pa:rcel # �
S unh cili v is�i o t�
Ph�a�s�� Sect�ioia tot #
�IZ �P �� f ` Improvement Permit
Permit Valid for Five Years No Ezpiration
Type of Facility: CX�'S� ��. New Addition Water Supply ��s�
# of Occupants # of Bedr oms _?� Projected Daily Flow 3(o D g.p.d. �
Proposed Wastewate.r �S 'stem: � . Type:
Proposed Repair: �nSPt-c,-C�1'�n Type:
Permit Conditions: U n CA V
Owner or Legal Represe
Authorized State Agent:
�- i n5 p«t � r�a
Fa�
Date:
Date: ��4 �3
The issuance of this pernrit by th� Health Deparhnent in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property owner to in s e that all Person County Planning and Zoning and Building Inspections requirements are me� This
Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compiiance with the provisions of the North Carolina `Laws and
Rulesfor Sewa�e Treatment and Disnosal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health
5pecialist warrants that the septic tank system will continue to function satisfactorily in the future or that the water supQly will remain
Authorization to Construct Wastewater. System
* See site plan and additional attachments (_�.
Proposed Waste�
New R
Type of Facility:
System:
_ Expansion
Tank Size: Septic Tank:
: Total Area: sq
Width ft
Distribution•
Authorized
C`:1
for Building Permit)
e Wastewater Flow _g.p.d.
LTAR• g.p.d./ ft 2
Basement _ Yes _ No
Requirements
Tank- gal
Length ft
Grease Trap:
Mazimum Trench Depth
�in So over: in Minimum Trench Separation:
Box S' Distribution Pressure Manifold
Expiration Date:
The type of system permitted is Conventional Innovative
the permit.
Owner/Legal Representative:
Date:
Date:
g�
in
ft
I accept the specifications of
PCHD7/30/2002
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Applicant:
Location:
Ta�x MaE� � � F�rcel �—,
Scihciivis�ion
Fh���s�e Sect�ion Lo# #'
L 1
�
Improvement Permit
Permit Valid for _ Five Years _ No Ezpiration
Type of ' '
# of Occupants of Bedrooms
Proposed Wastewater System:
Proposed Repair:
Permit Conditions:
New Addition Water Supply ��1�
Projected Daily Flow g.p.d.
Owner or Legal Representative Signature:
�� •� �
Authorized State Agent:
Type:
Type:
The issuance of this permit by the 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 met. This
Improvement Permit Is subject to revocatlon If the site plan, plat or the intended use changes. The Improvement Permit is not affected
by a change in ownership of the property. This permit was issued in compllance 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 Bnilding Permit)
* See site plan and additional attachments (�.
Proposed Wastewater Sys m: LL�'j �Cj��-,`anlLi Type � Wastewater Flow �.p.d.
New Repair� xpansion _ Soil LTAR: .� g.p.d./ ft 2
Type of Facility: ���� �i Basement _ Yes =-�Ido
Wastewater System Requirements
Tank Size: Septic Tank: �_ gal Pump Tank: N�A gal Grease Trap: �� gal
Drainfield: Total Area: � O sq ft Total Length a%J ft Maximum Trench Depth �� in
Width �_ ft Minimum Soil Cover: �_ in
ition: Distribution Box t/Serial Distribution
Specifications:
Authorized State Agent:
Permit Exnirat' Date:
The type of system permitted is _��"onventional
the permit.
Owner/Legal Representative: �
Innovative
Minimum Trench Separation: � ft
Operation Permit
Pressure Manifold
Date: c� c� �-{�Z
Alternative. I accept the specifications of
Date:
System Type (in accordance with Table Va) -�F •
The system has been installed in compliance with applicable North Carolina General Statute, Laws and Rules for Sewage Treatment and
Disposal, and all conditions of the Improvement Pertnit and Construction Authorization. Issuance of this permit does not guarantee that the
wastewater system will function properly for any ' e period of time.
Authorized State A ent: ��� Date: 3 a s�a
g
PCHD rev. O1/23/02
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Tax Map #: 1"f �1 . Parcel #: ��o
Zoning: Townshlp: ���t� L �' �� /�
Subdivislon• � N % � Sectlon: Lot•
Applicant• I�O��Ii'� Z,`c.Ka-Foo�� _
Location: b���� iDac� �a�,q ����- n��
;
Operation Permit
� System Type (In Accordance With Table Va): �
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
AUTHO TION. -
� ��-a� oa
A horized State Agent Date
6
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,� o i nt
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SiTE. SKETCH:
Ta.x Map #� Parcel #��
Section/Lot#
3-��-az..
Date
System components represent approximate �contours only. The contractor must, flag the system j�rior to
beginning t��t�rr,stalla�n to i� e that pr+npergrade is maintained
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i�Onn1 � Z�c�KaFo�Sc. , Taz� # �al P�cel# �=
ub � . . Section/Lot#
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: �irthorize�i Stat� Ageut - . � Date � . •
5',�r�t c�a�ot�e� a�ir�s�d a���r�ssrs �. g'':iie �r �,�g � s,grstea�s�� at��
� ' g �8as �as�i�ss #o � ���ei'gssr�de as sraarsrta�sted
a
l,�o��d.�� r�.�on•Mt�d .
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pn si�c '�av�� �ab � f i r�
pF add iki o�-�, Sa �� I Cov�'
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s� t�or��
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Applican�
Location:
T��x M�� � Parcel # • �
Su,hci!ivi�s�ion
Ph���s�e Sectio�a Lot #�
� a !� r
� Improvement Permit
Permit Valid for Five Years No Ezpiration
Type of Facility: CXi S�ti n New _ Addition Water Supply� ���^
# o f Occupants # o Be drooms �_ Projec te d D a i ly F l o w � v( n� g. p. d. �
Proposed Wastewater System: � . Type:
Proposed Repair: c� Z ati �� C�5 y� 2.cdut,f�b� Type: ��j��_
Permit Conditions: 1n 5 t� l I
�(�c7' O I c�S Fron� w c e(
in atuCfi I t / rUr1 %
. So�nd e.r�s �, ' n
Owner or Legaf Represen ti �
Authorized State Agent:
�,
tk � l!l c c� li �d 0
/�c t p NLcJ T�n K
,� L�nc. 3' dc�,p
Z'F c� td 5c P�ic '
3a l [a�1 `Tkn �
jc�' o/cis Fra r�, p�nd
und cr Ql�ivc d� Sl«�c.
�nl� /�s n a t 5t-�uc�urli %�
Date:
Date: �I'-4-03
The issuance of this permit by th� Health Department in does not guarantee the issuance of other permits. It is the responsibility of the
applicant/property 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 or 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 Zaws and
Rules for Sewage Treatment and Disposal 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 Sy tem: �Pu n-�� �n � D Ja�1� � �
New Rep� Expansiori _
TypeofFacility: Existirw __
Type %��� G Wastewater Flow �J�a� g.p.d.
Soil LTAR: • o? � $p.d./ ft 2
Basement Yes ✓No
ph�y j F Did 7anK t5 n�t �u^d. Wastewater System Requirements
K
Tank Size: Septic Tank: �� gal Pump Tank: � gal � Grease Trap: i^� l� gal
Drainfield: Total Area: �Q sq ft Total Length �(7 ft Mazimum Trench Depth � U in
Trench Width 3 ft Minimum Soil Cover: �.P in Mini.mum Trench Sepazation: �_ ft
Distribution: � Distribution Box Serial Distribution V Pressure Manifold
�ll�t,.� m�nl F��d �p�cvn.0 SP�-�i�Fi'ca-��'ons pr�v►dcd,
,-�—
Authorized State Agent:
Permit Exx
The type of system permitted is
the permit.
Owner/Lega1 Representative: _
Date: �'%-'�"(�3
Date:
Conventional �Innovative Altemative. I accept the specifications of
Date:
PCHD7/30/2002
���.�� II���.S��
___. __ � � � ���� f�_
IE;�-��������ll IH[�,�.1L�� Owner: l7(1(� 1�- Z I GI� �Oc75G
Tax Map: Aa1 Pazcel #: a(c Date: 'O
Li�e Tap Tap {Sch) Tap �low Line I.engtla �'lovv / foot
# Diarneger(�) { m) � (ft)
� z , � !a , o
2 � Z �� lao . os�
� Z �► � lao � os
4
5
6 -
7
8
9
10 �
c.�0 ft of line x 65 gal. per 100 ft =�� 0�,9(� ; 100 =�9' gal
75°lo x��. gal = � �S gal per dose a �� gal per minute (gpm) _�'low Itate
�ricHon Head
I,oss: l, a� ft per 100 ft of supply line x�� ft of supply. line =100 =� C1�1 ft
i I ft x 1.2 =.o"Z � ft of friction head
Manifold Size: � "�orce Main Size: c�" PVC
�otai Dynamic �ead =.�I ft of Elevation head +,�_ft of Pressure head +c��ft of
Friction Head = � � TDH � ,
g Zocllc� o� e�ur�u(cn�
Pump itequireanent: � GPM @��Q_ ft of ad
Drawdown: � 15� S�al per dose = 21 gal per inch = �3 inch drawdown per dose
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uce b,r 1/: %r taDUin� both :
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Size �lcrserial r'�vw GP 1�1
1� ,• Sched �40 �.5
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Se�bmersible � �a
Efflu�ent P� �•
9"
� Coacrete
Slock
d � '. • ,
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O A , 1 • . . . • • •
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r zi �r_ ■ ica _� � `�.r� _�
� s -� r .i • sir_ f- n
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l �� — � �� _ � << - � � �_ =. �� .
� � ...�-_
111 = 11l —' 1 I f= t l( =.,,�1�—�=`
• - . . � :r...�:
• � �� � � J � Gallo[t Tank
. •� • I
J
� p � r
� Scrpply Line To -� � �
d• Diare[er ScheduTe 40 PVC
� ,• Pipe
• lal Rz�p �ral �
s .
' Gate Valve
� Th=eaded Unian
• . Q�ec1c Valve
3/16" Syp�n Br�� F�vle
'� I�d�cx� gtr�s Am�ari All C�a'ds
� ALarm Flaat (elevation)
"pur�, on" Ftoat (elevation)
`' "Ptxap Of£' Flaac (���on) .
�;
� pUMP RATING
. .._—
PUMP SYSTEM DETAIL SSEET �
Pnmp Hust Be Rated To Deliver
GalLons Per Hinute
Agaiast �Feet Of Tota
Dynas¢ic Head (TDH) -
See Folloving Sheet For
Additional Specificativrts,
Notes, And Explanations.
1
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ZE�.�.s�� ���.�.]1 IL 33L��.Il� ��' o u�
Appiican� I�Orini C, Z��CI�FooS e,
Location: � � "
C��perat�on: Permit
S t T I Accordance With Table Va)• � �
ys em ype ( n . .
THfS SYSTEM HAS BEEN IN�?ALLED - IN COMPLIANCE WITH APPUCABLE NORTH
� CAROLINA GENERAL S'iATUTES, RULES .FOi� .SEWAGE��:TREATMENT AND DISPOSAL,
AND AL.L CONDITIONS OF THE IMPROVEMEPIT � PERMIT . AND CONSTRUCTION
A ORIZATION. . � � ..:_ .rk^�S� c��cs
� �. - . .. � . � �....�.�..� � :� ���s_�3-� � .. .
Authorized State �Agenfi � � � . � _ � � : • Date � • � � �
Instailed By:l� W�ndcll I�II �So� ��r�` Date: . � 1"(0'(0.3 ... . .. . .
oti� . .
. � . . . � . .. . - :- . 5� P,�Y L����.
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PCHD, rev. 07/29/02
a
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s���� z��� ��us��c-non� cs"'����Q..�sz �Typ� �i - i�
Tax Map #� a1 Parce! # c�? System Type (Tabie Va) ��� �
Owme�/Applicant� (Z.onni`c, `Z► c.(:.oF�s�- Subdivision � I �4
Address/Location � SeclPhase Lot #
. St2te ID/date 5 f4 Z
Capacity. i0o0 .
Tee and Fiter
Ba#fle
• Sealarrt . _ .
Riser if ap licable
Tank Outlet�. Seal
. Permanent Marker
Pu�p Tank
/Sealant
Wser
� � Pump-
�heck Valve/Gate Valve .
- tt-si on o e . .
,� �ioats/Switches � � � � � � � . . ..
Alanrt (visable and audible)
Rate (gpm)
Approved Pump Model
Blocic Under Pump
Pump Removal Rope/Chain
Distribution System
Serial Distribution '
ressure an o
Low Pressure Pipe �
Appr. Pipe Material and Grade
�� 11-5-R3
Width
�
Grade
Rock Depth and Quali
Dams/Stepd�wns etc.
Pressure Laterals
Hole Soacina
� - -� � w�� .��.� .. .
✓ Pipe Sieeve . � - � � �
�/ Tum-ups}Protectors
�Requined Setbacics
/ From Welis �.
� From Propert� lines �
._ _ .Structures/Basemerrts.:: � �.�
��:� rtc es rama � e ays �
�. 1�t�-� SurFace`Waters - � -
Public Water Supplies
Vertical Cuts >2 f�. .
Water Lines
Vehicle Traffic
� Easemerrts/Right of
�i']Bf
NI p Easements RecordE
5� �1�5-� e erator
N � � . Tri-Partate�AqreemE
�+ II'
��
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�
,
pcnd rev. 3113/01
u
PERSON COUNTY HEALTH DEPARTMENT
SiJBSURFACE WASTEWATER SYSTEM MONITORING REPORT
ly i3 �1 b o '3isA�, A�`l �b
Date of spection Sys em Installation Date Type Tax Map Parcel #
�l �i t ��..1 tos savRs. RO Raxc�v t� . tJ C. �`15`I �
Properiy Address
Instructions: Check yes or no for appropriate items and explain in space provided for rema:ks 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
infiitration and surface water diverted ?
Septic tank needs pumping ?
Inches of solids: Z- l``4'
Septic tank filter cleaned ?
EFFLUENT DOSING SYSTEM:
Require� pumps present & functional ?
High water alarm operating properly ?
Fioats, vaives, etc. in good condition ?
Control panel & components in good
condition ?
Effluent free of excess solids ?
Inches of solids(pump/dose ):
Elapsed time readings ? �
Counter readings ?
Drawdown rate:
YES / NO REMARKS
❑ / � - �-12r� �rl -r��Ja� N��+� ��£ �ro c�b�-o
1� i❑ t�L-,�St. c cL��,�► �i � � x-� Y�,�a.�
� � � � '��% �►flS �ifK.�r.��a L1P �r� rc�a�tZ.A
� / � s4A� � a�.T(S�a�, �i�E: "'►'�rltt UpS.
� � ❑
❑ � �
❑ / ❑
❑ � �
❑ � ❑
DISPOSAL FIELD:
Evidence of effluent surfacing ? ❑
Evidence of effluent ponding in trenches ?❑
Surface water effectively diverted ? '�
Div�rsions/swales properly maintained ? ❑
Vegetat:vP c�ver r_iair_tained ? �
Protected from tr�c/unauthorized uses ? 'e
uistrioutiuii devices in good condition ? �
Field free of settled or low areas ? �
/
/
/
/
/
/
�
/
�
G
■
■
■
■
■
���r�t t��i�,`c 1'�.U�.l�p t�►�, (iY i��� W iLt�
�i'r� �tL2��t1�1..
� C;�%tt�.r Q�L �1�os fi�- P�,,� t� ���..� � tLraC.
�-o �vn(' t�voW�S Q`( +�sfCYS
. A�w�t'�. •s +��a� ti�£. 'CS�rC l. �bct� l�G� s eavT
` ir�t'� `����� czr�► �'P�L.
t�a t�a� S�AI. �r L a�l. �.1l�t�(� �a�
: �?� ��r i�•'� .�tt�£O � �i�C '�
. 5acw� ti�.1.s�o�. £�rn+�C, �A�-L. C�E� r�cr:
LJ v4al
PRESSURE DISTRIBUTION SYSTEM: '� C.�Gn•av�R P`��' ��'�'���'p ��
Turnups/cleanouts/valves/taps intact & ��� v�� �� �.K, p� M����t�
accessible ? ❑ � �
Pressure head properly adjusted ? ❑ /� i�.X � S l��sS�a�.. ,
COMPLIANCE:
Compliant
Non-compliant
Needs Maintenance
I■
1:
►_�
r�w�iTivi�rwCuivli�lEivT�: C��h�D ��S �"�f1-£O A'LeUr�fl 'Y��-�kS ' �iln�'
�t�s `�ra 'i�rwvE -,�v,�- II�aa� �z�f�Ani� S-r�-a�r►s P2�sc.�-c ; N�� a�a1�
���a,�.�►�J► -�c �c�,►,c�. co,�c�.. 4�a��.. a� � �c�cs �ac��ct.�.�t � —
EHS