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624 Baileys Chapel Rd Davie County,NC Tax Parcel Report Wednesday, January 25, 2017 4� --------- ! � 624--'--'-------Y ___ ---- �a may'(� TR CRS 1 fl ,109 \Xv�\ + 125 � N f Fr ( X\ �f 191 111 ................................................................................................._........................................................................................................................................................................................................................,.......................................................�........................................._ WARNING: THIS IS NOT A SURVEY Parcel�Information ,� � � Parcel Number: H80000005201 Township: Shady Grove NCPIN Number: 5779526939 Municipality: Account Number: 8302317 Census Tract: 37059-804 Listed Owner 1: STUMP FRANKLIN A JR Voting Precinct: WEST SHADY GROVE Mailing Address 1: 624 BAILEYS CHAPEL RD Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27006-7143 Voluntary Ag.District: No Legal Description: 10 AC BAILEYS CHAPEL RD Fire Response District: ADVANCE Assessed Acreage: 9.86 Elementary School Zone: SHADY GROVE Deed Date: 6/2013 Middle School Zone: WILLIAM ELLIS Deed Book/Page: 009290368 Soil Types: PaD,PcB2,PcC2 Plat Book: Flood Zone: Plat Page: Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding&Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 161 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 County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to NC or arising out of the use or Inability to use the GIS data provided by this website. t t y t OPERATION PERMIT or ice se n v Davie County Health Department *CDP File Number 121447-1 210 Hospital StreetH8-000-00-052-01 s P.O. Box 848 County ID Number: Mocksville NC 27028 tEvaluated For: NEW Phone:336-753-6780 Fax:336-753-1680 ownship: Applicant: Frank Stump Property Owner: Jerry Phillip Smith Address: 780 McGregor Road Address: 2225 Tesh Road City: Winston-Salem City: Winston-Salem State/Zip: NC 27103 State/Zip: NC 27127 Phone#: �336,765-4036 Phone#: (336)650-0700 Pro a Location & Site Information Address/Road#: Subdivision: Phase: Lot: Bailey's Chapel Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, Left onto Hwy 801 going North. Road #of Bedrooms: 3 on Left in curve, #of People: *Water Supply: PUBLIC *IP Issued by: *System Classification/Description: *CA issued by: 2140-Nations,Robert Saprolite System? O Yes 9 No Design Flow: 3 6 0 *Distribution Type: Pump Required? 0 Yes No Soil Application Rate: 0 3 *Pre-Treatment: Drain field Nitrification Field 1 0 0 S4 ft. *System Type: No. Drain Lines 4 jamie barnes Installer: Total Trench Length: 4 0 0 ft. Certification M Trench Spacing: — 9 Deet O.C.ches O.C. *EHS: 2140-Nations,Robert ®F Trench Width: Inches — 3 Feet Date: 0 6 / 1 1 / a 0 1 4 Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: 1 a Inches Approval Status Maximum Trench De the � ' p 3 6 Inches Approved °' Disapproved Maximum Soil Cover: a 4 Inches Page 1 of 4 I ` CDP File Number 121447 - 1 County ID Number: 1-18-000-00-052-01 Septic Tank Manufacturer: s.hoaf Lat. STB: 760 Long: Gallons: 1000 Installer: Jamie bames Date: . Certification#: *EHS: 2140-Nations,Robert "Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter ST Marker: ❑ Yes ® No Date: 0 6 / 1 1 / a 0 1 4 Approval Status Reinforced Tank: ❑ Yes ® No ' J � �® Approved❑ Dlsapprovi ''' 1 Piece Tank: ❑ Yes ® NO � r Pump Tank Manufacturer: Installer: PT: Certification#: Gallons: *EHS: Date: / / Date: Riser Sealed ❑ Yes D No Riser Height: ❑ Yes D No (Min.6in.) i t :dcTank: ❑ Yes ❑ No ' ..3 Approval Saus Approvetl DDEsapprov�d ee Tank: ❑ Yes ❑ NOI L1 ====== .,... - � Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes D No Date: 3 33 Approved fittings ❑ Yes ❑ No Approval Status3 ❑ Approved❑ Dif isapproved ;,? Pump Requirement Pump Type: Installer: DosingVolume: - Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes D NO Check-valve El Yes ❑ NO Approval Status'' i3 3 � ws131fk�7 f $ PVC unions El Yes D No DSA roared D 3DPp lsa roved . pP, Vent Hole ❑ Yes ❑ NO Anti-siphon Hole ❑ Yes ❑ NO Page 2 of 4 121447 - 1 H8-000-00-052-01 CDP File Number County ID Number: Electric E ui ment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ NO Certification#: Box Adj.To Pump Tank 1:1Yes El No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ N0 *Activation Method: Date: ��,�,�� Approval Status t Alarm Audible El Yes ❑ No ❑ ,gpp",6" Dtsap'prove � Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: a`"'L Date of Issue: 0 6 / 1 1 / .2 0 1 4 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.1 900 et. Seq., and all conditions of the Improvement Permit and Construction Authorization.This property is served by a sewage septic system. Rule.1961 requires that a Type septic system meet the following criteria: Minimum System Review By The Local Health Department: Management Entity: Minimum System Inspection/Maintenance Frequency By Certified Operator: Reporting Frequency By Certified Operator: Rule.1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance 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. 0 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3 of 4 • OPERATION PERMIT Davie County Health Department CDP File Number: 121447 - 1 210 Hospital Street H8-000-00-052-01 P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Operation Permit Scale: , OBlock O N/A x 0 Q Qom• Page 4 of 4 P1 P2 P3 CONSTRUCTION r, For office Use only AUTHORIZATION *CDP File Number 121447- 1 Davie County Health Department County ID Number:H8-000-00-052-01 t 210 Hospital Street Evaluated For: NEW • -••• P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 a / 0 7 / a 0 1 9 Applicant: Frank Stump Property Owner: Jerry Phillip Smith Address: 780 McGregor Road Address: 2225 Tesh Road City: Winston-Salem CRY: Winston-Salem State/Zip: NC 27103 State2ip: NC 27127 Phone#: (336)765-4036 Phone#: (336)650-0700 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Bailey's Chapel Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, Left onto Hwy 801 going North. Road on Left in curve, #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: 3 6 Inches �Classiyfisctatmion_:te Minimum Soil Cover. a 4Saprolite SeOYes QNo Inches Design Flew: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 • 3 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: CONVENTIONAL 1-Piece: OYes QNo Pump Required: ()Yes QNo ()May Be Required Nitrification Field 1 2 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 4 1-Piece: OYes ONo Total Trench Length: 4 0 0 ft GPM-vs- ft. TDH Trench Spacing: - 9 Feet 0 C.Inches C Dosing Volume: Gallons Trench Width: - 3 QInches . Feet Grease Trap: Gallons 1 a inches Pre Treatment: ONSF OTS-1 OTS-II Aggregate Depth: Septic Tank Installer Grade Level Required: OI OII OIII OIV Pagel of 3 CDP-File Number_ 121447- 1 County ID Number: 1-18-000-00-052-01 r ❑ Open Pump System Sheet Repair System Required:OYes ONo' ONo, but has Available Space rDesign System Trench Spacing: 9 QInches 0. ification: — V Feet O.C. Trench Width: Inches w: 3 6 0 — 3 Feet Soil Application Rate: 0 - 3 Aggregate Depth: inches .� Minimum Trench Depth: 3 6 Inches 'System Classification/Description: Minimum Soil Cover. a 4 Inches Maximum Trench Depth: 3 6 'Proposed System: Inches NArification Field 1 a 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 4 'Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 0 0 ft Pump Required: QYes QNo QMay Be Required Pre Treatment: ONSF OTS-I OTS-II Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 7! "Permit Conditions The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. 2( This Authorization for wastewater System Construction shall be valid fora person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the sa metime 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 the application for a permit or Construction Authorization is found to have been Incorrect,falsified or changed,or the site Is attered,the permit or Construction Authortzation 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,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps.Signature: Date: 'Issued By: 2140-Nations.Robert Date of Issue: 0 a 0 7 / a 0 1 4 Authorized State Agent: Malfunction Log OYes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 ' CONSTRUCTION AUTHORIZATION 121447- 1 • , Davie County Health Department CDP File Number. 210 Hospital Street County File Number: "8-000-00-052-01 P.O.Box 848 Mocksville NC 27028 Date: 0 a / 0 3 / a 0 1 4 l O inch Drawing Drawing Type: Construction Authorization3 Scale: . OBtock / { 1 _..3 6ar 1 • 6 , 9 i r i ' _�-- ' 1 i a- I f , } e Yr it , Paae 3 of 3 IMPROVEMENT PERMIT For Office Use Only CDP File Number 121447-1 Davie County Health Department County ID Number: Hs-000-00-052-oi 210 Hospital Street P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 5/14/2018 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Frank StumpProperty Owner: Jerry Phillip Smith Address: 780 McGregor Road Address: 2225 Tesh Road City: Winston-Salem City: Winston-Salem State/Zip: NC 27103 State/Zip: NC 27127 Phone#: (336) 765-4036 Phone#: (336)650-0700 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Bailey's Chapel Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, Left onto Hwy 801 going North. Road #of Bedrooms: 3 on Left in curve, #of People: *Water Supply: PUBLIC System Specifications Initial S stem *Site Classification: Minimum Trench Depth: 4 Inches Saprolite System? O Yes 9 No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 3 1-Piece: O Yes ®No *System Classification/Description: Pump Required: OYes ®No O May Be Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes O No Repair System Required:(9 Yes ONo ONO, but has Available Space Repair System *Site Classification: PS Minimum Trench Depth: ol 4 Inches Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 Inches Pump Required: OYes ®No O May q be Required *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 121447- 1 County ID Number: H8-000-00-052-01 *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 this permit by the Health Department in no way 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 5 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 of the facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale of one inch equals no more than 60 feet,that includes:the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision 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 on the issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation if the site plan,plat,or intended use changes(NCGS 130A-335(Q).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(.1938(b)). Applicant/Legal Reps. Signature Required? Oyes (&No Applicant/Legal Reps. Signature: Date: *Issued By: 2244-Daywalt,Andrew Date of Issue: 0 5 / 1 4 / a 0 1 3 ent: OValid without Expiration? Authorized state A g O Create CA? ®Han Drawing O Import Drawing **Site Plan/Drawing attached.** Total Time:(HH:MM) 0 1 Hours 0 w Minutes Page 2 of 3 Activity Code: S-4-IP'S issued:new,valid for 60 mos. IMPROVEMENT PERMIT 121447 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: H8-000 00-052-01 Mocksville NC 27028 Date: / / O Inch Drawing Drawing Type: Improvement Permit Scale: 0 N/ABlock O N/A — ft. <5C/6,J) 5 6 , re4Q Page 3 of 3 P1 P2 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 121447 - 1 P.O.Box 848 H8-000-00-052-01 Mocksville NC 27028 County File Number: Date: .0.5./ 14 V2 0 13 Click below to import an image from an external location: Drawing Type: Improvement Permit Page 3 of 3 P1 P2 AI 'EIFOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC Davie County Environmental Health DOE ' 5i G EX 157,A:� P.O.Box 848/210 Hospital Street Alocksville,NC 27028 't?!T (336)753-6780/Fax(336)753-1680 C b}g r/LC' e �� (a, /D��••vnc�-aa--�Sz•Ct Application For: ❑Site Evaluation/Improvement Permit tXQhorization To Construct(ATC) ❑Both Type of Application: 17New System :'Repair to Existing System C Expansion/Modification of Existing System or Facility ***IMPORTANT"*THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name r' �v+rt f Contact Person j/iZt 5 ;1 r>i/n15o�1( Address 7{e`> >� 1�; c L v� �l7_ Home Phone City/State/ZIP_Lzsr��-,7r•�J- i1C ;H„�1/l 27/f�:�Business Phone �ji.-7t;7-ZS(�� Email L 2000 het,.,i,ci�.h Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged D G r NOTE: A survey plat or site plan must accompany this application. Included:IC-Site Plan i7 Plat(to scale) (Permit is valid for 60 months with site plan,no expiation with complete plat.) Owner's Name =j2 -,y K S P Phone Numbers 31--391'7,;r,-7 Owner's Address_79t-,, -c,t` ;Zp. City/State/Zip 1-1-5 &c -0 7iC,!� PropertyAddress City-- p t",4,uc E Lot Size 9.- to ,. ax PIN# 5-77. ,7Z L y.3') Subdivision Name(if applicable) Section/Lot# Directions To Site: 5 c c Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms L- #Bathrooms Garden Tub/Whirlpool!!Yes 5.46 Basement:Cites o Basement Plumbing: I-Yes IXu;a" '- ills IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY:: #Seats Type system requested: 1-16onventional ;'Accepted Cannovative DAltemative -.Other_ Water Supply Type:/County/City Water New Well ('Existing Well C Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?-Yes til o If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. 1 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 ]cit o th to se/fa 'i c ion,proposed 11 location and the location of any other amenities. mer's or owner's legal represen , sig? ,e Site Revisit Charge Date(s): a Client Notification Date: Date I I EHS: Sign given CYes ONo Account# Revised 11/06 Invoice# 1166' N EXISTING HAY BARN GEOTHERMAL 9 30'X16' LOOP AREA 170' ONVNER(S): FRANKLIN A. STUMP JR. & EXISTING PWR. POLE &, MARY B. STUMP DPCO ROUTE 634 BAILEYS CHAPEL RD. PROPOSED HOUSE ADVANCE,NC 27006 EXISTING 336-391-7387 FENCE �W PROPOSED DRIVEWAY d (605' LONG) 1335' LINTERS TRAIL 10' 50' 100' 200' 300' 400' 500' ` SCALE a '