260 Stage Coach Rd (2) Davie County,NC ; Tax Parcel Report Thursday, February 23, 2017
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WARNING: THIS IS NOT A SURVEY
Parcel Information ,
Parcel Number: J20000002005 Township: Calahaln
NCPIN Number: 5707580826 Municipality:
Account Number: 8307278 Census Tract: 37059-801
Listed Owner 1: NULPH RANDALL L Voting Precinct: SOUTH CALAHALN
Mailing Address 1: 260 STAGECOACH ROAD Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27028 Voluntary Ag.District: No
Legal Description: 1.25 AC STAGE COACH RD TR 3 Fire Response District: COUNTY LINE
Assessed Acreage: 1.25 Elementary School Zone: COOLEEMEE
Deed Date: 12/2016 Middle School Zone: SOUTH DAVIE
Deed Book/Page: 010370753 Soil Types: PcC2,CeB2
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 0.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 18060.00 Total Market Value: 18060.00
Total Assessed Value: 18060.00
O uvia�<' All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the
/'r County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
�OUpf NC or arising out of the use or inability to use the GIS data provided by this website.
OPERATION PERMIT or ice use Unly
p Davie County Health Department *CDP File Number 231039-1
210 Hospital Street $707580826
P.O.Box 848 County ID Number,
Mocksville NO 27028 Evaluated For NEW
Phone:336-753-6780 Fax:336-753-1680 Township=
Applicant: Scott Smith Property Owner. David Crump
Address: 82$ Piedmont Dr Address: 260 Stage Coach Rd
City: Lexington City: Mocksville
State2ip: NC 27295 State/Zip: NC 27028
Phone#: (336)782-1647 Phone#:
Pro a Location & Site information
Address/Road M 2d"D Subdivision: Phase: Lot:
Stage Coach Rd
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 64 West left on Davie Academy Rd. Right on
#of Bedrooms: 3
Stage Coach Rd
#of People: 2
*Water Supply: NEwwELL
*IP Issued by. 2140-Nauss,Robert *System Classification/Description:
TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS
*CA issued by: 2140.Nations.Robert
Saprolite System? (,}Yes QNo
Design Flow: 3 6 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
Oyes lallo
Soil Application Rate: 0 a 7 5 *Pre Treatment:
Drain field
rN
cation Field 1 3 0 9 Sq. *System Type: INFILTRATOR QUICK 4 STANDAR
rain Lines 5 Installer.
William Rueben Clayton III
Total Trench Length: 3 a 2 ft. Certification#: 2694
Trench Spacing: 9 Inches O.C.
Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: 3OlnchFeetes
Date: 0 2 / 0 3 1 2 0 1 3
Aggregate Depth: inches
Minimum Trench Depth: 3 6 inches
Minimum Soil Cover. .1 4 Inches Approval Status
Maximum Trench Depth' � � � p Approved Cl Dtsappiov+�ct
Inches
Maximum Soil Cover a 4 Inches
231039 - 1 5707580826
CDP Fite Number Septic Tank bounty id Numbe
Manufacturer. Shoaf Lat.
STB: 763 Long:
Gallons: 1000
Installer. William Rueben Clayton 111
Date: 1 1 / 0 7 / x 0 1 6 Certification#: 1694
'EH S: 2140-Natkm,Rout
"Fitter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. El Yes ID No
Date: 0 a / � 3 / � 0 1 7
; Approval Status ,,
Reinforced Tank: ❑ 'deg ® NO ��
1 PieceTank: ❑ Yes � No
'''C �ApArtived❑ Disapproved
Pump Tank
Manufacturer Installer
PT: Certification#:
Gallons: *EH S:
Date: / / Date:
RiserSeaied ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ No (Min.6 in.) �
Reinforces!Tank: ❑ Yes ❑ No y y
���,�❑yApprovet�❑ �Isapprovad�,
1 Piece Tank: ❑ Yes ❑ No r;y
Supply Line
CPipe Size: inch diameter Installer
Pipe Length: feet Certification#:
'Schedule: 'EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No
-A royal Status � ��
C] Approved❑ Qisapproved
u
Pump Type: installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches 'EH S:
*Cham:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No
3 , - ApA royal Status
PVC Unions ❑ Yes ❑ No - ❑ ApproYed❑ Qisapproued
Vent Hole ❑ Yes ❑ No y
Anti-siphon Hole ❑ Yes ❑ NO
CDP Fite Number 231039 - 1 County ID Number: 5707680826
Electric Equipment
rNEMA4XBoxorEquivalent ❑ Yes ❑ No Installer:ches Above Grade ❑ Yes ❑ No
CertificationAdj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date: /
";Approval Status
Alarrn Audible 0-1Yes , ❑ No
❑ Approved❑ Disapproved
Alarm visible [3 Yes ❑ No
2140-Nations,Robert
*Operation Permit completed by:
et��Authorized State Age Date of Issue: 0 a / 0 3 / a 0 1 7
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 III G. sewage septic system.
Rule .1961 requires that a Type TYPE III G. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System InspectionAAaintenance Frequency By Certified Operator:
WA
Reporting Frequency By Certified Operator.NIA
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywth a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a
public management entitywith a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a 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.
(DHand Drawing 41mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 231039- 1 '
Davie County Health Department CDP File Number:
210 Hospital Street 5707580826
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
Drawing DrawQN/Aing Type: Operation Permit Scale: , O = ft.
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t . Weft' Construction Permit For office u onto
Davie County Health Department *CDPFile Numter 231039
210 Hospital.Street PIN Numiber: 5707580826
P.O.Box 848
•` ''' Mocksville NC 27028 Tax Lot#: Tax Block#:
Phone:336-753-6780 Fax:336-753-1680 Evaluated Far. WELL
PERMIT VALID UNTIL: 1/17/2022
Property Owner: Randy Nulph . Applicant: Scott Smith
Address: 260 Stagecoach Road Address: 828 Piedmont Drive
City: Mocksville City: Lexington
Statelip: NC 27028 State/Zip: NC 27295
Phone#: Phone#: (336)782-1647
Property Location 8! Site information
AddresslRoad#: Subdivision: Phase: Lot:
Stage Coach Rd *Proposed use of Well:
Mocksville . NC 27028
If Other.
Latitude
Longitude Directions
Site Address:Stage Coach Rd Directions:Hwy 64 West left on Davie Academy Rd.
Right on Stage Coach Rd
Well Contractor information
Drilling Contractor Driller Registration
L._
ce.
IA (tQ
Permit Conditions
'Permit Conditions
,
Well location,construction and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of
the Local Health Department.The permit may be revoked at any tare for failure to complywith existing regulations.The siting of approved well construction
area(s)by the Health Department is to provide protection from the known possible sources of contamination.The approved well area(s)may not be changed
without written permission from an authorized representative of the Local Health Department.No volume of quality of water is guaranteed by the Health
Department.
*Issued By: 2140-Nations, Robert *Date of Issue; 0 r 1 , , 1 , 7 , / , a , 0 , 1 , 7 ,
Authorized State Agent: eHand Drawing Qimport Drawing
Owner/Applicant Signature: **Site Plan/Drawing attached.**
WELL.CONSTRUCTION PERMIT
as Davie County Health Department CDP File Number:'231039 --
210 Hospital Street
� 6707680826..
P.O.Box 848 County File Number:
y
Mocksville NC 27028 Date: 0 1 / 1 7 / 2 0 1 7
Q inch
Drawing Type: Well Permit Scale: " 0Block
ONta ft,
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APPLICATION FOR PRIVATE WELL PERMIT
Da�><e County Env><ronmentalHealth
'OBox 848/210'Hospital'Street
MoeksA11&* NC 27028
„ (33.6)753 6780 /Fax (336)753 1680
***IMPORTANT***
THIS APPLICATION CAA WOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name d oritact-Person
Address Home Phone
City/State/ZIP X Business Phone.
Email
Name on Permit if Different tha' Above
Mailing Address _ City/State/Zip
PROPERTY INFORMATION *Date House/Facili Corners'Fldg ed
NOTE: A survey t or Ise p1 st'accompany this,apphcation Included: ❑ Stte'Plan *Plat"(to scale)
Owner's Name Phone Number:
Owner's Address 1 'City/State/Zip NLQ (S1/i' Property
Address City
Lot Size 7C, Tax PIN# 67 U5Z(o
Subdivision Name(i app icable) Sectio jot
Directions To Site: .
DEVELOPMENT INFORMA
Permit Type: New Well Well Repair Well Abandonment Other(specify)
Facility Type: Residential Food Service Ch"urcfi Commercial '7"'"'_ 'Other
Are There Any Septic Systems Currently On The Site? YES NO
Do You Intend To Install A New Septic System On This Site? YES NO
TERMS AND CONDITIONS:
This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines
with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic
system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying
and marking the property lines and corners. The applicant is responsible for making the site accessible:
The plat or map of the site must include,to scale,showing the locations of:all property boundaries,at least one of which is
referenced to a minimum of two landmarks such as identified roads,intersections,streams or.lakes within 500 feet of proposed well
or well system;(B)all existing wells,identified by type of use,within 500 feet of proposed well or well system;(C)the proposed
well or well system;(D)any test borings within 500 feet of proposed well or well system;and(E)all sources of known or potential
groundwater contamination(such as septic tank systems;pesticide,chemical or fuel storage areas;animal feedlots,as defined by
G.S. 143-215.10B(5);landfills or other waste disposal areas)within 500 feet of the proposed well.
By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
determine the best location for a well.
���-sib l' I(�• 11
Applicant'!'Signature Date
Property owner or Owner's legal representative
1[�� I �K` DU)WrS a VOJW, !A,9117 Site Revisit Charge
y1� 6 5 Date(s):
Client Notification Date:
EHS:
11/7/2016
Account# 1
Invoice#
}
APPLICATION FOR PRIVATE WELL PERMIT
(331)753-6780
***IMPORTANT' **
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name to be Billed r., Contact PersonScat�
Billing Address r Home Phone '7 Qa /IoLi1
ity/State/ZIP : .� . L 72 S Business Phone
Email ,�o
ame on Permit if Different t an Above_ aN ) N c,\roL.
ailin Address 2(,0 igj —City/State/Zipoc1C G
PROPERTY INFORMATION *Date House/Facility Corners Flagged
OTE: A survey or must accompany this application. Included: Site Plan Plat (to scale)
Owner's Name { :4 ^.-NIP Phone Number
wner's Address_Q b O 00, 5 {.cy, ,Q R City/State/Zip A Mkj a l l i. U,c Z7 n2f
Property Address City ALWX- 1,.l/. pc., 77 01-8
Lot Size Tax PIN#17o7Sdoo.2v
Subdivision Name(if applicable) Section/Lot#
Directions To Site:t4oq Cj.&+ t Jb*„«
DEVELOPMENT INFO TION
Permit Type: New Well Well Repair Well Abandonment Other(specify)
Facility Type: Residential Food Service Church Commercial Other
Are There Any Septic Systems Currently On The Site? YES NO
o You Intend To Install A New Septic System On This Site? YES t/ NO
TERMS AND CONDITIONS:
This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines
with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic
system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying
and marking the property lines and corners. The applicant is responsible for making the site accessible.
By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
determine the best location for a well.
Si Date
Site Revisit Charge
LH
):
Notification Date:
7/30/09 Account#
Invoice#
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PROnSIONK LLL SVRKaM S I CERTIFICATE OF
IOWNERSHIP AND DEDICATION
I CERTiY MAT I AM THE OWNER Or THE PROPERTY DESCDBED MINOR SUMVI90N OF
• DA EON.WHICH IS LOCATED D THE HIS SO WION 04 PLAN
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DDLI TYALL EAMMENTS AM EMOAMANCE PROPERTY OF SUSAN ELIZABETH EVANS
A �,,P� _� �.�_•, MAY NOT BE SHOWN HEREON
• RLwr ONrSIt N✓✓�DAIE ,7L_Y REFERENCES:•!_l._
srm or °°NEW mnrr OL x PLAT OF SURVEY FOR
MaT M NAr a Ml to LARCH tNM mnrrw.Dl• DX 41K,PO.SOS
DA 3132..FOL 30 .SUSAN E EVANS
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NM Y,COATED S11B01M9011 REGXS 0,TH, ANA [W ND Or LNN VARIANCE; IWG(6MI�.E.NC 27020
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CklaTC&'DAVIECOAmATWNT (336)722-1444 FT7-E7�F��
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DATE-, 02/06/15 SCALE 1'-50' ZONE: R-A u t
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Davie County, NC Tax Parcel Report Monday, November 7, 2016
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WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: J200000020 Township: Calahaln
NCPIN Number: 5707590061 Municipality:
Account Number: 82532497 Census Tract: 37059-801
Listed Owner 1: CRUMP DAVID ALLEN SR Voting Precinct: SOUTH CALAHALN
Mailing Address 1: 260 STAGE COACH RD Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27028-0000 Voluntary Ag.District: No
Legal Description: 4.959 AC STAGE COACH RD(2.00 AC) Fire Response District: COUNTY LINE
Assessed Acreage: 2.00 Elementary School Zone: COOLEEMEE
Deed Date: 12/2010 Middle School Zone: SOUTH DAVIE
Deed Book lPage: 008441012 Soil Types: PcC2,CeB2
Plat Book: 12 Flood Zone:
Plat Page: 41 Watershed Overlay: DAVIE COUNTY
Building Value: 66590.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 24630.00 Total Market Value: 91220.00
Total Assessed Value: 91220.00
�kyfA All deb is provided as is without warranty or guarantee of any kind either expressed or Implied including but not limited to the
oD Di70 -9 CVIe CoUnt�', Impliedwa—ties of merchantability or fitness for a particular use.All users of Davie County's CISwebsit.shall hold harmless the
County of Davla,North Carolina,Its agents,consufianb,contractors or employees from any and all claims or causes of action due to
or arising out of the use or Inability to use the GIS data provided by this website.
HEALTH DEPARTMENT RELEASEForOfficeuseOnly
'CDP File Number 158683- 1
C-6 —,
FoDavie County Health Department J2-000-00-020
210 Hospital Street County ID Number:Evaluated For:P.O. Box 848 HDR/WWC
"' Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 1 0 / 0 8 / x 0 1 9
UNTIL:— —
Applicant: Susan Evans Property Owner: Susan Evans
Address: 260 Stage Coach Rd Address: 260 Stage Coach Rd
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)492-2765 Phone#: (336)492-2765
Property Location&Site Information
Addres4260 Stage Coach Road Subdivision: Phase: Lot:
Road# Mocksville NC 27028
SINGLE FAMILY Township:
*Structure:
Directions
#of Bedrooms: 2 #of People: Right on Valley Rd.left on Hwy 64 W,Left on Davie Academy Rd.then
right on Stage Coach Rd.
'Water Supply: N/A
Basement: F-1 Yes F-1 No
Type of Business:
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Addition
`Release Conditions
750
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? O Yes ONO
Applicant/Legal Reps. Signattire •Date:
*Issued By: 2140-Nations,Robert *Date of Issue: 1 0 / 0 8 / .1 0 1 4
Authorized State Agent:
**Site Plan/Drawing attached.**
®Hand Drawing OlmportDrawing
HEALTH DEPARTMENT RELEASE
Davie County Health Department CDP File Number:
158683 1
a �b�
210 Hospital Street J2-000-00-020
P.O.sox 848
County File Number:
Mocksville NC 27028 Date: 10 / 08 / .2014
4
O Inch
Scale: O Block ft.
Drawing Type: Health Department Release ON/A
a 0 CL.Ur(L
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goy
Page 2 of 2
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street CDP File Number: 158683 - 1
P.O. Box 848 12-000-00-020
Mocksville NC 27028 County File Number:
Date: 10 / 0 8 / .1014
Drawing Type:
Health Department Release
I
Page 2 of 2
DaNic County Hcalth Department
'98836 lromnental Hczdffi Section
848 •
0 RECEIVED 210 Hospitrtl Street. PTIS
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1.1� Ccfuricr# :0940-06DJie: Z�
mtc: 4/zbl/q Mocksvillc, NC 2702$ Recetrea b . !�/i
Phone:(33G)-753-6780 Fax:(:33 w-7.53-1680
ON-SITE WASTEWATER CERTIFICATION �� �?�l�'�6
(cheek One) Replacement Remodeling Reconnection
Name- Phone Nuc her r,��c (Home)
Mailing Address4� � �� tti,, '71 (%ktork)
Email Address-
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Detailed DirectionsTo Site: r) 0_ f- r+
PropertvAddress:
Please Fill In The FollovAring Information About The EXISTING Facility-:
Name System Installed Under: Type Of Facility: 51&LI l '
Date System Inst,-tlled.(Month,7)ate.-Yeir): ....Number Of Bedrooms.—i Niunber Of People-__J__
- Is The Facility Currently Vacant? Yes Yes Na If Yes,For How Long?
Any 1<:t1o1vn Probleazls7 Yes If Yes,F.xphaln:
Please Fill In The Following Information About The AWWFaeility:
Type Of Facility: ` 2f"t . Number Of 13edraonis: �Itunber of People
�-----—
Pool Size: Garage Size.— Other:�. r
Requested( v- .� . Date Requested:_L__= , - L �
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For Environmental Health Office Usc Only
Approved Disapproved
cumments:
Environmental Health Specialist Date:
"Me signing of tl> s form by the Environmental Health Staff is in no way intended.nor should be taken as a guarantee
(extended or limited)that the on•sitr wastewater system will function properly ror any given period of time.
Payme �hcck Money Order 'tAmount:S_J00, _llatr:_
Puid Fiy: Received B}
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