NCG550906_application_20200117

North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pal McCrory John E.Skvada,l'l
Govemor WATER QUALITY PERMITTING SECTION Secretary
u
PERMIT N.A.MEfd`VNERSHIP CHANGE REQUEST
This corm is for ownership clutages or name elaunges or Npim."s wastewater permits.
"Pcrmittee"rcferen ..s:isting pemitt holds
_ "An-,-, i-ant"refercm"€Ian for th:.c°.,r rshi;; n.ta;r: 1tan L.
1. NPQES Permit No.(for which Mc,cf v,-e<s mquesteel): N COO
or
Certificate of Coverage#: NCG55090 (o
If. Existing Permittee Information:
a. Permit issued to(company name):
b. Person legally responsible for permit:
Firs T411 Last
l itle
P
it Holder Mailing Ad ess
City State Zip
P ne F
c. Facility name:
d. Facility's physical address:
7ss
y State zip
e. Facility contact person: )
First M1 Last Phone
111. Applicant Information:
a. Request for change is a result of Change in ownership of the facility
Name change of the facility or owner
If odterplease erpluin:
b. Permit issued to(company name):
c. Person legally responsible for permit:
First 14II Last -
Title

d. Facility name;
r . -7"
e. Facility's physical address; �— '�q ��� I-N,
- Addre"
Cit. Stag; i Zip
f. Facility contact person: y- 'Y [t_r_.
First ml Last
Title
Phoa5 r A- aim ddress�
c 1
IV. Will the permitted facility continue to conduct the same commercial industrial acti-vities conducted prior to
this ownership or name change?
F1 Y,�.s rr
C],""No(please explain) A.tD xi--I C. 4
If applicable,the applicant shall submit a major permit modification request to DWR. A major modification shall be
defined as one that increases the volume, increases the pollutant load, results in a significant relocation ofthe
discharge point,or results in a change in the characteristics of the waste generated.
V. Required Items: TUIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change and or ownership change requests,
?, Legal documentation of the transfer of ownership(such as relevant pages of a contract deed,or a bill of sale)is
required for an ownership change request. Articles of incorporation are not sufficient for an ownership change.
Applicable regulations:40 CFR 122A1,alb CFR 122 61 and 15A NCAC 02H .0114
........_.............................................................................................................
The certifications below must be completed and signed 17_,both the permit holder prior to the change(Permittee).and the
new applicant in the case of an ownership change request. For a name change request,the signed Applicant's Certification
is sufficient.
I'EI .IITTEE CERTIFICATION(Permit holder prior to ownership change):
st t ia€this application for a name ownership change has been rewiewwed and is accurate and complete to the
best of lino ge. I understand that if all required parts of this application are not completed and that if all required
support rag information is not included,this application package v ilf be returned as incomplete.
Signatur Dal
APPLICANT,CERTIFICATION
I . .
I, 1i aAes t t this application for a name ownership change has been re%iewed and is accurate and complete to the
best of my knowledge. I understand that if all required parts of this application are not completed and that if all required
suppo ing information iVot included,this application package,vill be returned as incomplete.
L �
-
Signature
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
NPDES PERMIT NAME,OWNERSHIP CHANGE.REQUEST

11 18 2019 07:39 OWNERSHIP 69269361 1 PROPERTY DESCRIPTION TAX DESCRIPTION MAP NUMBER CARD#
LAVOIE PAUL R DUNAWAY/Pl/L7/H&L CUNNINGHAM A14 58
LAVOIE WENDY RECORD NUMBER: 16069 1/ 1
299 SOUTHPOINT TRL PLATBOOK/PAGE/DATE: 185 ROUTE: HY 108 050
SE:MORA,NC 27343-7172 NO:00000 00000 SUBDIVISION: 4035 LISTER: PLC 10/3/2019
DEED: 1017 101 9 11 2019$600,000 299 SOUTHPOINT TRL SEMORA BOAT DOCK #: 2216 REVIEWER: PLC 10 3 2019
TOPO STREET UTILITIES NOTES AC
ROLLING PAVED WELL GOOD WATERJExC VIEW
+ SEPTIC CORRECT F 19 0.8900
q u• ELECTRIC
CLASS SIZE BASERATE * ACF * ADJ AD]RATE * UNTT5 o LNDVALUE
1 3 WTRVIEW3 0.8 30000 1.0A 1 0.99 1 304950 1 0.899 1 2714pq
ACREAGE FACTOR: 6 FRONTAGE FACTOR: LAND VALUE 27140
OTHER FEATURES SIZE SASERATE I COND I A03 RATE; UNITS VALUE
01 1 19 C PIERS 4* 36 19.8 0.9 17.9 14 257
sr
1' 2 19 C PIERS 28* 17 18.3 0.9 16.5 47 786
3 60 B BTHSEOFP 28* 12 38.4 0.9 34. 33 1162
4 16 8 BOAT HSE 28* 32 34.3 0.9 30.8 89 2766
s n• of �' S 162 B BTHSESTG 8*20 45.2 0.9 40.71 1 651
6 101B GARAGE 22* 22 31.8 0.9 Z8.6 481 1388
OTHER FEATURES VALUE: 7013
FOUNDATION XTR_FINISH ROOF TYPE ROOF MT'RL SIZE/QTY
es s• w CONCBLCK CEMBOARD GABLE ASPHSHNG 1.5400 STHT
u• rr
4 BDRM
WALL FINSIH MOORS HEAT&AIR HEAT FUEL BLDING#
DRY WALL TILE CENTRAL ELECTRIC
CARPET CENT A/C 1
HARDWOOD
IMPROVEMENT TYPE: Dwelling GRADE:I B I AYB:I 1988 J, L
I CONDITION: A I DE-PLR TABLE: loo SQ FT TABLE:
DIMENSIONS: 01=N28E32S28W32Area:896;01=N34WISS34Ei5Area:510;01=N5E26S19W14N14W 12Area:326;60=S6E21N6W21Area.126,80-N5E20S5W2oArea:ID0;88=N
6E20N9E13S15W33Area:315.01-S6EllN6W31Area:66•TotalArea:2339
STRUCTURE SKETCH-SF* STHT = AREA RATE * GRDE + HEAT f EXWL * WLHT a ADJRATIr * AREA - RPCN * DEPF * CNDF »VALU
01 01 SNG FAML 89 1.5 138 79.3 B 2.5 2.2 0.9 79.0 138 10914 0.8 94955
5 BATHS 4880. 2440 0.8 21228
88 88 DECK 31 1.0 31 14.1 1. 14.i 31 444 0.8 3870
01 01 SNG FAML 51 2.0 102 79.3 2.5 2.2 0.94 79.0 102 8067 0,8 70185
0101 SNG FAML 32 1.0 32 79.3 2.5 2.2 1.0 84.1 32 2743 0.8 23864
0101 SNG FAML 6 1.0 6 79.3 2.51 2.2 1.0 84.1 555 0.8 4831
80 80 PORCH 12 1. 12 27.1 1.0 27.1 i2341 0.8 2974
80 80 PORCH 10 1. 10 28.3 1.0 28.3 ]16
0 7A-44 1 2466
2792 HSF 3333 TSF RPCN-92.37/HSF 257899 VALU-80.36/HSF 224373
STRUCTURE VALUE 22437
CARD 1 VALUE 56591
VALUATION THIS CARD + OTHER CARD a VALUE PREV-VAL P-N% OTHER CARDS VALUE
LAND 271406 271406 155750 0.57 TOTAL VALUE 56as9!
OTHER FEAT 70132 70132 70132 0.74
STRUCTURE 224373 224373 228140 1,02
TOTAL 565911 565911 435691 1.30 NBHD ADJUSTMENT: 1.000 * 565911=565911
TAX YEAR: 2020 (775611) Group:0 APPRAISED VALUE 565911
Person CoUn NC REVAL YEAR:2013 DEFERRED VALUE 0 TANABLEVALUE 565