159 Ellis Ln Davie County,NC ' Tax Parcel Report Wednesday, February 15, 2017
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WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: C700000065 Township: Farmington
NCPIN Number: 5862564698 Municipality:
Account Number: 24126000 Census Tract: 37059-802
Listed Owner 1: ELLIS JOHN WESLEY Voting Precinct: SMITH GROVE
Mailing Address 1: 1540 YADKIN VALLEY ROAD Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNTY R-20
State: NC Zoning Overlay: DAVIE COUNTY QD
Zip Code: 27006-8714 Voluntary Ag.District: No
Legal Description: .730 ac HWY 801 Fire Response District: SMITH GROVE
Assessed Acreage: 1.13 Elementary School Zone: PINEBROOK
Deed Date: 6/2014 Middle School Zone: NORTH DAVIE
Deed Book/Page: 009590965 Soil Types: PcC2,CeB2
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 39000.00 Outbuilding&Extra 11340.00
Freatures Value:
Land Value: 20380.00 Total Market Value: 70720.00
Total Assessed Value: 70720.00
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 warrantles of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the
County of Davis,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
"OU ty c NC or arising out of the use or Inability to use the GIS data provided by this website.
OPERATION PERMIT or ice se n v
4 fes. Davie County Health Department *CDP Fite Number 234275-1 .
210 Hospital Street 5862564698
P.O. Box 848 County ID Number.
Mocksville NC 27028 Evaluated For REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
F
ant: John Ellis rAddress:
rty Owner: John Ellis
ss: 159 Ellis Lane 159 Ellis Lane
yAdvance y: Advance
State2ip: NC 27006 Statefzip: NC 27006
Phone#: (336)909-5203 1, Phone#: (336)909-5203
Property Location & Site Information
Address/Road M Subdivision: Phase: Lot:
7
61 4
NC Directions
Structure: SINGLE FAMILY 140, east to exit#180. This is Hwy 801 go, North at
light. Ellis Lane will be on left past Church
#of Bedrooms: 2
#of People:
*Vi/ater Supply: EXISTING WELL
*IP issued by. ''System Classification/Description:
TYPE It A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
SaproliteSystem? QYes .0No
Design Flow: 2 4 0 'Distribution Type: Pump Required?
QYes QNa
Soil Application Rate: 0 - 3 *Pre Treatment:
Drain field
r
on Field SQ ft *System Type:
n Lines Installer:
Total Trench Length: Certification#:
Trench Spacing: — Inches O.C.
()Feet O.C. EHS:
Trench Width. Olnches
Feet Date:
Aggregate Depth: inches
Minimum Trench Depth:
Inches
Minimum Soil Cover. Inches Approval Status;
Maximum Trench Depth: Inches Approved Disapproved
❑
Maximum Soil Cover
Inches
CDP Fite Number 234275- 1 County ID Number: 5862564698
Septic Tank
Manufacturer. Shoaf Lat.
STB.
760 Long:
Gallons: 1080
Installer. Brian McDaniel
Certification#: ilia
Date: l 0 / a l Jae 1 6
` *EH S: 2140-Nations.Robert
'Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. ❑ Yes E2 No Date: _ a / 0 9 / x 0 1 7
Reinforced Tank: ❑ Yes No Approval Status
1 Piece Tank: ❑ Yes No Approved❑ `Disapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: 'EH S:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeight: El Yes ❑ NO (Min.6 in.) A rxrvalStatus
Pp
einforcedTank: ❑ Yes ❑ No o Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer.
Pipe Length: feet Certification#:
'EH S:
'Schedule:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ElNa Approval Status
D Approved❑ :Disapproved
Pump Rgq1j1r_gment
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ NO Approval Status„
PVC unions ❑ Yes EJNo ❑ Appirtwed Disapprovetl
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Ye5 ❑ NO
CDPfile Number 234275- 1 County ID Number: 62564698
y
Electric Equipment
NEMA 4X Box or Equivalent p Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ No Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ No /
*Activation Method: Date:
App at Status
Alarm Audible ❑ Yes ❑ No
Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140•Nations,Robert
*Operation Permit completed by:
Authorized State Agent. __,.,,. Date of Issue: 0 a 0 9 2 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 u A sewage septic system.
Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Maximum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator.N/A
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 entitywRh 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 bya public or private management entty, 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.
(Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department CDP File'Number: 234276 - 1
210 Hospital Street 5862564698
P.O.Box s48 County File Number:
Mocksville NC 27028 Date:
0Inch
Drawin Drawing Type: Operation Permit Scale: , ON A k ft.
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CONSTRUCTION For Office use only
AUTHORIZATION *CDP File Number 234275-1
ORDavie County Health Department CountyID Number.5862564698
210 Hospital StreetEvaluated For: REPAIR
P.O. Box 848. .- Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 2 / 0 8 / a 0 a a
Applicant: John Ellis Property Owner. John Ellis
Address: 159 Ellis Lane Address: 159 Ellis Lane
City: Advance City: Advance
State2ip: NC 27006 State0p: NC 27006
Phone#: (336)909-5203 Phone#: (336)909-5203
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
NC Directions
Structure: SINGLE FAMILY 1-40, east to exit#180. This is Hwy 801 go, North at light.
#of Bedrooms: 2 Ellis Lane will be on left past Church
#of People:
*Water Supply: EXISTING WELL
System Specifications
Minimum Trench Depth:
r
assification: Provisionally Suitable Inches
Minimum Soil Cover.e System? QYes QNo Inches
Flow: Maximum Trench Depth: Inches
Soil Application Rate: Maximum Soil Cover: Inches
*System Classification/Description: 'Distribution Type: GRAVITY-SERIAL
TYPE 111 G.OTHER NON-CONN.TRENCH SYSTEMS Septic Tank:
1 0 0 0 Gallons
'Proposed System: 25%REDUCTION 1-Piece: QYes ONo
Pump Required: QYes @No OMay Be Required
Nitrification Field
Sq. ft. Pump Tank: Gallons
No. Drain Lines 1-Piece:QYes ONo
Total Trench Length: ft GPM vs— ft. TDH
Trench Spacing: Inches O.C.
8Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
8Feet Grease Trap: Gallons
_ _
Aggregate Depth: inches
PreTreatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 OIII OIV
Donn 1 of l
CDP File Number 2$4275 - 1 County ID Number. 62564698
❑ Open Pump System Stieet
Repair System Required:OYes ONo @No, but has Available Space
rDesign
System Trench Spacing: Q Inches 0. .
ification: ProvisionailySuitable Feet O.C.
w: Trench Width: Q FeetS
Soil Application Rate: Aggregate Depth: inches
Minimum Trench Depth:
*System Classification/Description: Inches
Minimum Soil Cover.
Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: Inches
Nitrification Field Sq.
Maximum Soil Cover.
Inches
ft. "
No. Drain Lines *Distribution Type:
,Total Trench Length: Pump Required: Oyes @No OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-II
"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 bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater system Construction shall bevalid fora person equal to the period of validity of the Improvement Permit,not
to exceed fives years,and may be Issued at the sametime the improvement Permit Issued(NCGS 130A-336(11)}If the installation has not been
completed during the period of validity of the Construction Permit,the Information submitted In the application for a permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site Is attered,the permttorConstruction Authorization shall become
Invalid,and may be suspended or revoked(.1937(8)).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,malntenarscr,monitoring,reporting and repair
(1938(b)).
ApplicanULegal Reps.Signature Required? OYes ONo
Applicant/Legal Reps. Signature• Date:-
*Issued By: Date of Issue:2140-Nations,Robert 0 . / 0 8 / 2 0 1 7
_ - • - - - - -
Authorized State Agent: Malfunction Log @YeS
@Hand Drawing OlmportDrawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 234275- 1
' Davie County Health Department CDP File Number.
210 Hospital Street 5862564698
P.O.Box 848 County File Number;
Mocksville NC 27028 Date; 0 .1 / 0 8 / 20 1 7
O inch
Drawing Drawing Type: Construction Authorization Scale: , O = ft.
/A
QNN/A
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 234275- 1
P.O.Box 848 5862564698
Mocksville NC 27028 County File Number.
Date: .0_:1 / 0 8 / 2 0 1 7
Click below to Import an image from an external location: Drawing Type:Construction Authorization
Rob
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST Tj24
APPLICATION IP/ATC OSWW REPAIR a wAjie!
Name v �/ 1 15 Telephone Number ,?3&
Address /Pq tXY IVC_
Mailing Address (if different from above)
Email Address:
Subdivision Name _ Lot#
D' ections e I cr 0Gt/Q/
� L
Date System Installed Name System Installed Under
Type Facility /674(tse— Number Bedrooms cP- Number People Served
Type Water Supply Specific Problem Occurring
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent 8
Initial Fee Date REHS
Revisit Charge Date Reason3lj��s
Revised 2-2011
r DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST 60
APPLICATION IP/ATC OSWW REPAIR
Name `JO l i v 5 Telephone Number t ; 90 / ✓Z�.�
Address I 5�9 LS&S Ll4w (1041de- Alt-
Mailing
lt Mailing Address (if different from above) s `a
Email Address:
Subdivision Name _ Lo
D' ection /V ! t ° 6"( `''d" O u/af
L z
Date System Installed . NametSystem Installed Under
Type Facility /'/0VS(2- Number B' drodms cP- Number People Served ' 1
Type Water Supply Specific Problem Occurring ,t��!,1
Date Requested 'F Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT-'10 THE BEST OF MY
KNOWLEDGE,AND THAT I,UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011 Lr ? .
y
++ 6 0
Site Address: NC
*Failing System Code: SEPTIC OR PUMP TANK
*Replacement System Code: SEPTIC OR PUMP TANK
Age (whole number): 6 a
*Was it Initial or Repair: INITIAL.
*Type of Distribution: GRAVITY-SERIAL
LTAR Today: 0 . 3
Design Flow(GPD): a 4 0
*Type of Failure Code: DAMAGED
*Primary Cause Code: TANK OR PUMP TANK NOT WATERTIGHT