NCG550862_Owner (Name Change)_20210726

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ROY COOPER :~Y `tIlte-
Governor ,, Ie_. car
DIONNE DELLI-GATTI N.
Secretary
S:DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCOO / / / / or "' = , F oVol4\
1. Facility Name: : D O 1'\)e_ nst�r�rf,
bWr`\ Q��
II. NEW OWNER/NAME INFORMATI
RECEIVED
1. This request for a name change is a result of:
4 a. Change in ownership of property/company
JUL 2 6 2pz�
_b. Name change only
NCDE( /DWPJNPDES
c. Other(please explain):
2. New owner's name (name to be put on permit):
\-Q c.\'\-e cCNOo\Q,t'S
3. New owner's or signing official's name and title: \—\ c\-e.Ac\cr R040\�D-C
(Person legally repohsible for
permit)
(Title)
4. Mailing address: 60q \,...± ooin hekrt\v City:�ti„ it r,`
State: '‘' C— Zip Code: `k"711 k Phone: (`jt01 )1V_cUlli J
E-mail address: \�o.c c cue c`.( C3 c � ��.C(wor\
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
4��,i1. This completed application form
,i2. Legal documentation of the transfer of ownership (such as a property deed, articles
of incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
DE � North Carolina Department of Environmental Quality I Division of Water Resources
Noa cnaou an Raleigh Regional Office 13800 Barrett Drive I Raleigh,North Carolina 27609
'`)RTh m m� ..uuably /`� 919.791.4200

Applicant's Certification:
I, \ S Q.�S Q-r' 0�svS , attest that this application for a
name/ownership change has been reviewed 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 supporting information and attachments are not
included, this application package will be returned as incomplete.
• Signature L,,A r QAn Date:`1W AI
THE COMPLETED APPLICATION PACT?GE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING
ADDDRESS:
NC DEQ/ DWR/ NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617 ,
1
D E ‘, North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office 13800 Barrett Drive I Raleigh,North Carolina 27609
NORTH CAROUNA
oepartmam of[r.wnmen,ai uua,y� 919.791.4200

ROY COOPER
,,:`
MICHAEL S. REGAN
•, w' A.;4s '. - S. DANIEL SMITH
•
Erie r{'i 7, is?lid`!k'
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N C G 5 5 O 8 ( a
II. Please provide the following for the requested change (revised CoC).
a. Request for change is a result of: ►:1 Change in ownership of the ri.of ` ' E
n Name change of the facility oi-owne D
If other please explain: JUL 2 2021
b. CoC will be issued to (person's name
or company name, if applicable):
c. Owner: person legally responsible for
CoC: \_\ 4c\p—rc
• First MI Last
Title
Permit Holder Mailing Address
City State Zip
Phone mail Address
d. Facility name (if applicable):
e. Facility address:
Address
City State Zip
f. Facility contact person:
[if different from Owner] First MI Last
( )
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
Ki Yes �J
❑ No (please explain)
Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
V. ARE INCOMPLETE OR MISSING:
n This completed application is required for both facility-name change and/or facility ownership
change requests.
Legal documentation of the transfer of ownership (such as a property deed, relevant pages of a
contract, or a bill of sale) is required for an ownership change request.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
1 Tts attest that this application for a name/ownership change has been reviewed 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 supporting information is not included, this application package will be
returned as incomplete.
77\1A\D-A
Signature
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617

Durham County, NC Property Report 7/7/2021
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_ ParcelrIErformat►on , 1,
PIN: 0860-45-25-3193 Parcel ID: 193386
Acreage: 0.542 Land Use: RES/ 1-FAMILY
Deed Book: 008628 Deed Page: 000063
Plat Book: 000054 Plat Page: 000028
Subdivision: SHAW HILLS ESTATES Site Address: 532 OLIVE BRANCH RD
Owner Name: ROGERS LISA FLETCHER Owner Address: 4009 LEAH LN
Land Value: $65,650.00 null
Total Value: $180,915.00 DURHAM , NC 27712
Building Value: $115,265.00
Sale Price: $195,000.00
Tax Maps are not to be used to establish boundaries and/or size. Use for such is soley the reponsibility of the user.
O LP

• i-OR I<<EGISI RATIO;i
Sharon,A.Cans
REG'STER OF DEEDS
Du,hs4i: id:.
• 2til9 Apr 050, :. 3i PM
F .8620 PG:63.64
DEEP
FEE 5?6 OC
t E TRUMENT?;'O'i y:i 1 C'EOF•
E KC:'ETAX.S;;9U00
TREDFEARVS
111111111111111 1111111 1
2019010605
NORTH CAROLINA
GENERAL WARRANTY DEED
Excise Tax: $ 390.00 Recording Time,Book and Page
Tax Map No. Parcel Identifier No. 193386
Mail after recording to: Grantee . if d� j ,t, Stu. a� �
This instrument was prepared by: Edmund D. Milam,Jr., Esq.
THIS DEED made this day of Pi¢r$ ,2019 by and between
GRANTOR
CARLA C.PERKINS, unmarried
Grantor's Address:
GRANTEE
LISA FLETCHER ROGERS
Property Address: 532 Olive Branch Road,Durham,N.C. 27703
The designation Grantor and Grantee as used herein shall include said parties,their heirs,successors,and assigns,
and shall include singular, plural,masculine,feminine or neuter as required by context.
WITNESSETH,that the Grantor,for a valuable consideration paid by the Grantee,the receipt of which is hereby
acknowledged,has and by these presents does grant,bargain,sell and convey unto the Grantee in fee simple,all that
certain lot or parcel of land and more particularly described as follows:
BEING all of Lots 7 and 8, Block F, SHAW HILLS SUBDIVISION, as recorded in Plat Book 54,
Page 28,Durham County Registry.

All or a portion of the property hereinabove described was acquired by Grantor by instrument recorded in
Book 6494, Page 235,Durham County Registry.
,
A map showing the above described property is recorded in Plat Book 54 Page 28, Durham County Registry, as
referenced within this instrument.
The above described property❑ does ❑ does not include the primary residence of the Grantor.
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto
belonging to the Grantee in fee simple.
And the Grantor covenants with the Grantee,that Grantor is seized of the premises in fee simple, has the right to
convey the same in fee simple,that title is marketable and free ,(3,clear of all encumbrances,and that Grantor will
warrant and defend the title against the lawful claims of a. iersons whomsoever except for the exceptions
hereinafter stated.
Title to the property hereinabove described is subject to the following exceptions:
Easements and restrictions of record
Ad Valorem taxes not yet due and payable
IN WITNESS WHEREOF,the Grantor has hereunto set her hand and seal, or if corporate, has caused
this instrument to be signed in its corporate name by its duly authorized officer(s),the day and year first
, ,
above written.
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;i W ; 2Az (SEAL)
Carla C. Perkins r
STATE OF (I(..
COUNTY OF ') 4iIy j
I certify that Carla C.Perkins, unmarried personally appeared before me this day, acknowledging the due
execution of the foregoing instrument for the purposes set forth herein.
Witness my hand and official stamp or seal,this the S day of CAI( 1 ,2019 .
My Commission Expires: S°"-3� U a! hi , (9 `,,. ,pj
Notary Public
Print Notary Name: Q( I rct , g
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Seal ®�, Gscn►�►�ssio `/.�.�
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1,: `8-202O ‘.C)."