NCG551190_owner name change_20220110

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
S. DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
January 10, 2022
Edward A. Garcia
2628 Wessex Rd
Winston-Salem, NC 27106
Subject: General Permit NCG550000
Certificate of Coverage (CoC) NCG551190
2628 Wessex Rd
Forsyth County
Dear Permittee:
The Division has approved your request to transfer coverage under the subject General Permit.
Accordingly, the Division hereby issues you a revised version of NCG551190, along with a copy of
NCG550000. Discard any earlier versions of the permit and use this version until further notice. This CoC
is issued pursuant to the requirements of North Carolina General Statue 143-215.1 and the Memorandum of
Agreement between North Carolina and the US Environmental Protection agency dated October 15, 2007 [or
as subsequently amended].
PLEASE NOTE: Your facility discharges to a class C waterbody. Therefore, you will use the limits
and monitoring frequencies found in Part I, section C. (1.) of NCG550000.
If any parts, measurement frequencies or sampling requirements contained in this General Permit
are unacceptable to you, you have the right to request an individual permit by submitting an individual
permit application. Unless such demand is made, the certificate of coverage shall be final and binding.
This CoC is not transferable except after notice to the Division. The Division may require
modification or revocation and reissuance of the CoC. Contact the Winston-Salem Regional Office
prior to any sale or transfer of the permitted facility. Regional Office staff will assist you in
documenting the transfer of this CoC.
This permit does not affect the legal requirements to obtain any other State, Federal, or Local
governmental permit that may be required. If you have any questions concerning the requirements of the
General Permit, please contact Derek Denard of the NPDES staff [[e-mail]].
cc: NPDES file
NORT
Department of Environmental Dual
Sincerely,
li V.7)7
.
for S. Daniel Smith
Director, Division of Water Resources
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617
919.707.9000

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG551190
DISCHARGE OF DOMESTIC WASTEWATER FROM SINGLE FAMILY RESIDENCES AND
OTHER 100% DOMESTIC DISCHARGES WITH SIMILAR CHARACTERISTICS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission, and
the Federal Water Pollution Control Act, as amended,
Edward A. Garcia
is hereby authorized to discharge <1000 gallons per day of domestic wastewater from a
facility located at
2628 Wessex Rd
Winston-Salem
Forsyth County
to receiving waters designated as Oil Mill Branch, currently a class C stream in subbasin 03-07-04
of the Yadkin -Pee Dee River Basin in accordance with the effluent limitations, monitoring
requirements, and other conditions set forth in Parts I, II, and III hereof.
This certificate of coverage takes effect 1/10/2022.
This Certificate of Coverage shall remain valid for the duration of the General Permit.
Signed this day 1/10/2022
ii 144
for S. Daniel Smith
Director, Division of Water Resources
By Authority of the Environmental Management Commission

ROY COOPER
Governor
ELIZABETH S. BISER
secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
c
G
5
II. Please provide the following for the requeste -change (revised CoC).
a. Request for change is a result of: kal Change in ownership of the residence/property
❑ Name change of the facility or owner
If other please explain:
b. CoC will be issued to (person's name
or company name, if applicable):
c. Owner: person legally responsible for
CoC:
d. Facility name (if applicable):
e. Facility address:
f. Facility contact person:
[if different from Owner]
F_AvvIvic A Ce4r
First MT Last
i e
0.5c W sSoc Td
m HolderlitintAddress
W hSS tri'-7104
City State zip
(33�) 714 - 7117 I,, 5 mcv.
Phone E-mail
4)-( vt5S+4 ika
ess
W thS'lvin- hi A 7\ L_ 0 6
City State Zip
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
North Groins Depwrnnnit dfmbo wnntsi Quaky I Division of Water Resources
512 North Salisbury Street 11617 MA service center I Raleigh. North Carolina 27699-1617
919.707.9000

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
iv Will this permitted facility continue to discharge the same volume and type of wastewater as
ales
this ownership or name change?
alYes
❑ No (please explain)
V.
Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
WJNCOMPLETE OR MISSING:
This completed application is required for both facility -name change and/or facility ownership
ange 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.
APPL C, ANT CERTIFICATION
I, EA 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 incompl
Signature
/7/)
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
[e-mail]

• Book 3556 Page 2660
2020044382 00300
FORSYTH CO. NC FEE $26.00
STATE OF NC REAL ESTATE EXTX
S670.00
PRESENTED & RECORDED
10/022020 04:26:11 PM
LYNNE JOHNSON
REGISTER OF DEEDS
BY: CHELSEA B POLLOCK
DPTY
BK: RE 3556
PG: 2660 - 2661
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $670.00
Parcel Identifier No. 5897-82-3313.000
Verified by
By:
, 20
County on the
day of
Mail/Box to: Grantee at: 2628 WESSEX ROAD, W-S, NC 27106
This instrument was prepared by Heather J. Kiger. a licensed North Carolina attorney. Delinquent taxes, if
any, to be paid by closing attorney to the county tax collector upon disbursement of closing proceeds.
Brief description: Lot 31, Buckingham Park Subdivision, PB 22, PG 79, Forsyth County North Carolina
THIS DEED made this? (d day of -4-�
, 2020, by and between
GRANTOR
TERRY LYNN BRIDGE
AND WIFE
JANET ANN COOPER -BRIDGE
FORWARDING ADDRESS:
871 LAKE CAROLYN PKWY, #472
IRVING, TX 75039
PROPERTY ADDRESS IS IS NOT
GRANTOR'S PRIMARY RESIDENCE
GRANTEE
EDWARD GARCIA
AND WIFE
ALEXANDRA KLEIN
PROPERTY ADDRESS:
2628 WESSEX ROAD
WINSTON SALEM, NC 27106
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 situated FORSYTII County, North Carolina and more
particularly described as follows:
Being all of Lot 31, Buckingham Park Subdivision, recorded in Plat Book 22, Page 79, Forsyth
County Registry.
submitted electronically by "Heather Kiger Law PLLC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Forsyth county Register of Deeds.

Excise Tax: $670.00
Parcel Identifier No. 5897-82_3313.000
Verified by
By:
NORTH CAROLINA GENERAL WARRANTY DEED
County on the
Mail/Box to: Grantee at: 2628 WESSEX ROAD W_
S NC 27106
This instrument was sre. b
an
to be aid b Heather J. Kier a licensed North Carolina attorne Dan uent tax
closin attorne to the count tax collector u son disbursement of closin • 'roceeds.
Brief description: Lot 31, Buckingham Park Subdivision, PB 22, PG 79, Forsyth County North Carolina
THIS DEED made this f l d day of �� /
2020, by and between
GRANTOR
day of
20
a red
TERRY LYNN BRIDGE
AND WIFE
JANET ANN COOPER -BRIDGE
FORWARDING ADDRESS:
871 LAKE CAROLYN PKWY, #472
IRVING, TX 75039
PROPERTY ADDRESS IS IS NOT
GRANTOR'S PRIMARY RESIDENCE
GRANTEE
EDWARD GARCIA
AND WIFE
ALEXANDRA KLEIN
PROPERTY ADDRESS:
2628 WESSEX ROAD
WINSTON SALEM, NC 27106
1f
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 situated FORSYTH County, North Carolina and more
particularly described as follows:
Being all of Lot 31, Buckingham Park Subdivision, recorded in Plat Book 22, Page 79, Forsyth
County Registry.

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 and clear of all encumbrances, and
that Grantor will warrant and defend the title against the lawful claims of all persons whomsoever, other
than the following exceptions: Subject to all easements, restrictions and rights -of -way of record, if any,
and ad valorem taxes for 2020 and subsequent years.
IN WITNESS WHEREOF, the Grantor has duly executed t foregoing as of the . and year
first above written.
ANN 0
SEAL)
(SEAL)
State of NG — County of
I, l'k isle N N l f/t'Lldt j'1 , a Notary Public of 1'II 'y County, State of
r((� , certify that TERRY LYNN BRIDGE, personally appeared before me this
day and acknowledged the execution of the foregoing instrument.
stamp or seal this j4I day of
nd and Notarial
...et
(SF3AL7 N40TAR
• A
uBLlG•
State of i��%•
— County of
My Commission Expires:
0 oil ba
, 2020.
I���IoG►nni•e
a Notary Public of greVk'Lr... County, State of
certify that JANET ANN COOPER -BRIDGE, personally appeared before
me this day and acknowledged the execution of the foregoing instrument.
Witness my hand and Notarial stamp or seal this 2n4 day of C bv'
2020.
(SEAL)
s nie N �y
ter, ,•
OTA
C , f
pp , 1
' A�D L lC
My Commission Expires:
Notary Public