243 Gibson Way (3) Davie County,NC, Tax Parcel Report Wednesday, February 15, 2017
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WARNING: THIS IS NOT A SURVEY
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-° '; Parcel Information= _
Parcel Number: N50000004401 Township: Jerusalem
NCPIN Number: 5745516640 Municipality:
Account Number: 12421750 Census Tract: 37059-807
Listed Owner 1: CAMP MANNA MINISTRIES INC Voting Precinct: JERUSALEM
Mailing Address 1: PO BOX 795 Planning Jurisdiction: Davie County
City: COOLEEMEE Zoning Class: DAVIE COUNTY R-20
State: NC Zoning Overlay: DAVIE COUNTY CZOD
Zip Code: 27014-0000 Voluntary Ag.District: No
Legal Description: 39.049 AC OFF PINE RIDGE Fire Response District: JERUSALEM
Assessed Acreage: 38.87 Elementary School Zone: COOLEEMEE
Deed Date: 3/1995 Middle School Zone: SOUTH DAVIE
Deed Book/Page: 001790756 Soil Types: SeB,PcB2,RnC,PcC2,EnB,RnD,EnC,ChA
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 577940.00Outbuilding 8r Extra 42560.00
Freatures Value:
Land Value: 250820.00 Total Market Value: 871320.00
Total Assessed Value: 871320.00
AV All data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
°1 Davie County, implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the
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County of Davis,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
�OUN'�l NC or arising out of the use or Inability to use the GIS data provided by this website.
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'OPERATION PERMIT or I tee use Only
Davie County Health Department *CDP File Number .192750-.1
210 Hospital Street
P.O.Box 848 Counfy ID Number.
Mocksville NC 27028 Evaluated For: NEW
Phone:336-753.6780 Fax:336-753-1680 Township:
FApplicant Camp Manna Ministries/Stan Property owner: Camp Manna Ministries/Stan
Address: 243 Gibson Way Address: 243 Gibson Way
CRY: Mocksville CRY: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone : (336)284-2709 Phone#: (336)284-2709
PropeLty Location & Site information
Address/Road#: Subdivision: Phase: Lot:
243 Glbson Way
Mocksville NC 27028 Directions
Structure: CHURCH Gibson Way
#of Bedrooms:
#of People:
*Water Supply: EXISTING WELL
*IP issued by. 2140-Nations,Robert *System Class ificationtDescription:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? { Yes @No
Design Flow: a 0 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
QYes ONo
Sol!Application Rate: 0 a 5 *Pre Treatment:
Drain field
Nitrification Field 8 0 0 Sq. ft. *System Type: INFILTRATOROUICK4STAND
ARD
No. Drain Lines Brian McDaniel
i
Installer:
Total Trench Length: a 0 0 ft. Certification#: 1118
Trench Spacing: — 9 FeetO.C.4
*EH S: 2140•Nations,Robert
Trench Width: 3 inches
Feet Date: 0 9 / 1 5 / .2 0 1 5
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 inches AporovaM Status
Maximum Trench Depth: 3 6 Q Approvetl Q Disapproved
Inches j
Maximum Soil Cover. a 4
` Inches
CDP File Number 192750 - 1 Septic Tank County ID Number:
Manufacturer. Shoal Lat.
STB: 760
Lang:
Gallons: 1000
Installer'. Brian McDaniel
Certification#: 1118
Date: 0 7 / 1 1 12 0 1 5
*EH S: 2140-Nations,Robert
"Filter Brand: POLYLOKPL-122 With Pipe Adapter
1 5
ST Marker. C] Yes No
Date: .0 9 1 1 5 / a f3
Reinforced Tank: ❑ Yes ❑ NO ApprovatSttus ;
�' r❑ Approved❑��Isapproved�,'
1 Piece Tank: ❑ Yes ® NO �
Pump Tank
Manufacturer; Installer:
PT: Certification#:
Gallons: "EH S:
Date: I I Date:
RiserSealed ❑ Yes ❑ No
RiserHegtjt:.❑ Yes ❑ No (Mln.6 in.)
�� Apprcnral status - ���'�
Reinforced Tank: ❑ Yes ❑ No
._ ;�,� Approved CI d�sappro�ed ,;
❑ .Yes __- ❑ No
1 Piece Tank: f��. f�%, ✓{ �.��,.,����.
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
"Schedule: 'ENS:
Pressure Rated ❑ Yes ❑ No Date: /
Approved fittings ❑ Yes ❑ No Approval Status f
❑ Approved❑ Disapproved
Pu13eq!jlreMent
Pump Type: Installer.
Dosing Volume: - Gal Certification#:
Draw Down: Inches 'ENS:
'Chain: I I
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Approval Matas,
PVC Unions ❑ Yes ❑ No ❑ Approved❑ Disappraued
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 192750 - 1 County ID Number:
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No 'ENS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status,:
Alarm Audible ❑ Yes ❑ N o ❑ Approved❑ Disapproves
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robed
'Operation Permit completed by,
Authorized State Agent: Date of Issue: 0 9 / 1 5 / 2 0 1 5
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE It A. sewage septic system.
Rule.1961 requires that a Type -TYPE It A- septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator. NIA
Rule.1961 requires that a Type IV and V septic systems designed fora homelbusiness owner must maintain a valid contract
with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entity with a certified operatorforthe life of the septic system.
Rule.1961 (2)(e)requires a contract shall be executed between the system owner and a management ently prior to the
issuance of an Operation Permit for a system required to be maintained bya public or private management entity, unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
GHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department CDP File Number: 192750 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
OBloDrawing Drawing Type: Operation Permit Scale: , ON/A = ft.
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CONSTRUCTION For office use only
'AUTHORIZATION r*CDPFife Number 192750- 1
Davie County Health Department y ID Number:
210 Hospital Street Evaluated For NEW
.off. P.O.Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 4 / 1 6 / a 0 a 0
Applicant: Camp Manna Ministries/Stan Riddle Property Owner: Camp Manna Ministries/Stan Riddle
Address: 243 Gibson Way Address: 243 Gibson Way
City: Mocksville City: Mocksville
Stategip: NC 27028 State/Zip: NC 27028
Phone# (336)284-2709 Phone#: (336)284-2709
Property Location & Site Information
FAddress/Road#: Subdivision: Phase: Lot:
on Way
e NC 27028 Directions
Structure: CHURCH Gibson Way
#of Bedrooms:
#of People:
"Water Supply: EXISTING WELL
System Specifications
Minimum Trench Depth: a 4
rDesigan
ssification: Provisionally Suitable Inches
System? Minimum Soil Cover
y OYes @No 1 a Inches
low: a 0 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 5 Maximum Soil Cover: a 4 Inches
"System Classification/Description: "Distribution Type:
TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
'Proposed System: 25%REDUCTION 1-Piece: OYes @No
Pump Required: OYes @No 0May Be Required
Nitrification Field 8 0 0 Sq.ft. Pump Tank: Gallons
No.Drain Lines a 1-Piece: OYes ONo
Total Trench Length: a 0 0 GPM—vs— ft. TDH
Trench Spacing: — Inches O.C.
9 . Feet O.C. Dosing Volume: Gallons
Trench Width: inches
3 @Feet Grease Trap: LGallons
Aggregate Depth: p
inches Pre-Treatment: ONSF OTS-1TS-11
Septic Tank Installer Grade Level;Required: 01 011 0111
Dana I of Z
CDP File Number 192750- 1 County ID Number. 9 ,
❑ Open Pump System Sheet
Repair System Required:Wes ONo ONo, but has Available Space
rDesign
System Trench Spacing: Inches 0. .
ification: Provisionally Suitable E*03 9Feet O.C.
Trench Width: 0Inches
w: a 0 0 _ 3 . Feet
Soil Application Rate: 0 - a 2 5 Aggregate Depth: inches
*System Classification/Description:/Description: Minimum Trench Depth: a 4 Inches
TYPE it A.CONV,SYSTEM(SINGLE-FAMILY OR480,GPD OR LESS) Minimum Soil Cover. '1 2 Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
0 � Sq.ft. Maximum Soil Cover: a 4
Nitrification Field Inches
t3
No. Drain Lines "Distribution Type: ;GRAVITY-PARALLEL(eq.d-box)
a
TotalTrench Length: 0 0 ft. Pump Required: OYes ONo OMay Be Required
PreTreatment: ONSF OTS-1 OTS-ll
"Site Modifications
,No grading or construction activity is allowed in,areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate goveming bodies in meeting their requirements. ;
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permi%not
to exceed five years,and may be issued atthe sametime the Improvement Permit issued(NCGS 130A-336(b)).If the Installation has not been
completed during the period of validity of the Construction Permit,the Information submitted in theapplication for a permit or Constriction
Authorization is found to have been Incorrect falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be msponsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1s38(b)).
Applicant/Legal Reps.Signature Required? Oyes ONo
Applicant/Legal Reps.Signature: Date:,
'Issued By: 2140-Nations,Robert Date of Issue: . 0 4 / 1 6 / 2 0 1 5
Authorized State Agent:
Malfunction Log OYes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number:
210 Hospital Street
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 0 4 / 1 6 / a 0 1 5
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . . QOM
Block = ft.
7
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' -IMPROVEMENT PERMIT Forofflct#Use only.
"CDP File Number 192750-1
Davie County Health Department
210 Hospital Street County ID Number
., P.O.Box 848 Evaluated For: NEW
..mow,.
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax:336-753-1680 PER I,IIT VALID UNTIL 4/16/2020
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Camp Manna Ministries/Stan Property owner: Camp Manna Ministries/Stan
Address: 243 Gibson Way Address: 243 Gibson Way
CRY Mocksville City: Mocksville
StatetZip: NC 27028 State)Zip: NC 27028
Phone#:, (336)284-2709 Phone#: (338)284-2709,
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
243 Gibson Way
Mocksville NC 27028 Directions
Structure: CHURCH Gibson Way
#of Bedrooms:
#of People:
"Water Suppty: EXISTING WELL
System Specifications
nitial S sy tem
*SIteZTassii'ica�ion—Provisionally Suitable
Minimum Trench Depth: a 4 Inches
Saprotite System? QYes @No Maximum Trench Depth:
3 6 Inches
Design Flow: a 0 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 0 . a 5 1-Piece: QYes QNo
*System Class ificationlDescription: Pump Required: QYes 0N 0May,Be Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
"Proposed System: 1-Piece: QYes QNo
Repair System Required:@Yes, ONO ONO, but has Available Space
Repair System
"Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: - a a Maximum Trench Depth: 3 6 Inches7
s
"System Classification/Description: Required: Yes
n/Description: O Q No Q May be Required
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25%REDUCTION
Pagel of 3
CDP File Number 192750 - 1 County ID Number.
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of thispermit bythe Health Department in noway guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
Site Plan The Improvement Permit shall be valid for o years from date of issue with a site plan(means a drawing not necessarily drawn to
scale that shows the existing and proposed property lines with dimensions,the location ofthefaciitty and appurtenances,the
site forttme proposed Wastewatersystem,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
q surveyor,drawn to a scale of oneinch equals no morethan so fee%that Includes:the specific location of the proposed facility
and appurtenances,the site for the proposed,Wastewater system,land the location of water supplies and surface waters. Plat
also means,forsubdivision'lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may impose conditions an the Issuance and may revoke the permlts for failure of
the system to satisfy the conditions,the rules,or this article:This permit is subject to revocation If the site pian,plat,or Intended
use changes(NCGS 130A-335(1)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance;monitoring,
reporting,and repair(.1838(b))
Applicant/Legal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps_Signature: Date: /
*Issued By_ 2140-Nations,Robert Date of Issue: 0 4 / 1 6 / .2 0 1 5
Authorized State A ent: tOValid without Expiration?
(i�Create CA?
@Hand Drawing Olmport Drawing
**Site ;Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT 192750 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.sox 848 County File Number:
Mocksville NC 27028 Date: J J
Q Inch
DraWjnjjL Drawing Type: Improvement Permit Scale: . , 0810 k
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�ATION FR-SITE VALUATION/ITAPROVEMENT PERMIT &ATC
�'"�Lj vie ounty Environmental Health Box 848/210 Hospital Street
Mocksville,NC 27028 WWI 0i-
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9a�0' (336)753-6780/Fax(336)753-1680 qy.
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Application For: ❑ Site uation/Improvement Permit ❑Authorization To Construct(ATC) Both
Type of Application: gNewSystem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility V
***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name (1,0 M 0 1a VI no- R-(S-(J�Ps Contact Person r 7P t c(j le
Address 1,\ 1,1 6.0 Home Phone 3 3 6 - 2 8 —a70"l
City/State/ZIP _ ac,kS v i Iln CJ Business Phone 33h —�2 q-- 2a 7
Email n-�6
Name on Permit/ATC if Di erent than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name Phone Number
Owner's Address City/State/Zip
PropertyAddress ZL15 C11 bsw W aM City
Lot Size_qZ OWe S Ta PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
Specify Problem Occurring:
IF RESIDENCE FILL OUT THE BOX BELOW
FI
eople #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business ft embl u Total Square Footage of Building 5"oo o #People 2-2 5—
#
#Sinks -'� _ #Commodes I # Showers_0 #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: B6onventional 21 ccepted .❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water ❑New Well O&ting Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? /Yes ❑ o
Ifyes,whattype? o55'bIe- Yi+c -e,
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging
or ial' the ho a/fac' 'ty location,proposed well location and the location of any other amenities.
Property owner's or owner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
I .
i
Sign given ❑Yes ❑No Account# a v
Revised 11106 Invoice#
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
S1
& eiddk 61',65i4i t0n
00-M r A0,0 v16L 42 Aeras
33& 2gLl- .ZED1 i-f 1.� _ ,
Water Supply: On-Site Well Community Public /
Evaluation By: Auger Boring Pit / Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH
Texture groupL� GL
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group 3 C_
Consistence S
Structure S
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
• Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS r
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE A/
,SITE CLASSIFICATION: EVALUATION BY: ✓v�����5
LONG-TERM ACCEPTANCE RATE: 6.a Q.'a- OTHER(S)PRESENT: t r!4K
• .��. �i cS�CI n �'i t
REMARKS:
LEGEND
Landscape Position
R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE '
�Q15�
VFR-Very friable FR-Friable F1-Firm VFI-Very firm EFI-Extremely firm
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
,SBK-Subangular blocky PL-Platy PR Prismatic
Mineralogy
1:1,2:1,Mixed
LYQt�
Horizon depth-In inches
Depth of fill In inches
Restrictive horizon Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised)