NCG550709_Owner (Name Change)_20220207 (2)

STATE w ,
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NC DEPARTMENT OF ENVIRONMENTAL QUALITY
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41 i DIVISION OF WATER RESOURCES
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WATER QUALITY PERMITTING SECTION
NORTH CAROLINA NPDES PERMITTING
Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO° / / / / or NCG55/0/T/0/3
1. Facility Name: /5J'Y NC. /1 '>' Wei%
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
RECEIVED
b. Name change only
F
FS 0 7 2022
c. Other(please explain):
NCDEQ/DWR/NPDES
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title: //ate M / 1?Ac,
(Person 'gully responsible for permit)
/V/e14-7.4'e_./'
(Title)
4. Mailing address:.50OF /67LuZ4GW, `?%'1 City: X`JaG,,
State: /IVG Zip Code: 67/F/ 73 Phone: ( 5. (?) _303 - $,'
E-mail address: bit 0-11,. f1fl r7', 2,40 Cyin , ,/ corn
III. FACILITY AND DISCHARGE INFORMATION
1. Will the waste stream for the facility remain the same as under the previous owner? Yes Fr/No ❑
2. Will the treatment system and discharge location remain the same? Yes I"No ❑
"No Responses"
If either or both of these questions are answered "No"then more information will be needed to review the
request. Please attach documentation to describe and explain the changes to the facility activities, waste
stream, treatment process or outfall location. The Division may not be able to process the Permit
Name/Ownership Change request and may require that the new owner file a new permit application.
jNorth Carolina Department of Environmental Quality I Division of Water Quality
) 512 Noah Salisbury Street l 1617 Mail Service Center I Raleigh,Noah Carolina 27699-1617
wr. r '�:°��/ 919.707.9000

NPDES Name and Ownership Change
Page 2 of 2
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:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
3. Information to document facility, waste stream, treatment system or outfall changes as noted in
item III above (if appropriate)
Applicant's Certification:J
I, ig/'i�/'1 /ti' a-c /2 , 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. I understand that Permit Name/Ownership Change can only take place through action
taken by the Division of Water Resources and that no actions on my part or the part of my company
result in the automatic transfer of permit coverage.
Signature: Date: 00.-/03/ a .
THE COMPLETED APPLICATION PACKAGE, 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
Version 07/2021

.
NORTH CAROLINA
GENERAL WARRANTY DEED
Excise Tax: S364.00
Parcel Identifier No.: 6952-0461-8937.000
Brief description for index: Lts 16,17, 18,19,20,21,22,23,Sec 1 T.D.Preston
Mail deed/taxes after recording to Grantee:
This instrument was prepared by: Patti D.Dobbins,Attorney at Law
THIS DEED made this l7 day of '7 q.. ,2021 by and between
GRANTOR: GRANTEE:
MADISON COVE PROPERTIES,LLC,a SOUTHERN ROOTS,LLC,a North Carolina
Delaware Limited Liability Limited Liability
Address: 9239 Greyston Drive
Deham Springs,LA 70726 Property Address: 1539 NC 65 Hwy.W.
Walnut Cove,NC 27052
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.
WITNESSTH,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 in
STOKES County,North Carolina and more particularly described as follows:
See Exhibit A attached hereto and incorporated herein by reference.
All or a portion of the property hereinabove described was acquired by Grantor by instrument recorded in Book 725, Page 1171,
STOKES County Registry.
"This instrument prepared by:PATTI D.DOBBINS,a licensed North Carolina attorney.Delinquent taxes,if any,to be paid by the
closing attorney to the county tax collector upon disbursement of closing proceeds."

A map showing the above described property is recorded in Plat Book 108,Page 169,and referenced within this instrument
Does the above described property include the primary residence? ❑ YES I X I NO
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 has done nothing to impair such title as Grantor received,and Grantor will
warrant and defend the title against the lawful claims of all persons whomsoever except for the exceptions hereinafter stated.
Title to the property hereinabove described is subject to the following exceptions:
Restrictive covenants,easements and rights of way of record,if any.
Ad valorem taxes for the current year.
IN WITNESS WHEREOF,the Grantor has hereunto set his hand and seal, or if corporate, has caused this instrument to be signed in its
corporate name by its duly authorized officer by authority of its Board of Directors,the day and year first above written.
MADISON COVE PROPERTIES,LLC
By:
CARL ' • ; •
Title: Managing Member
STATE OF Fl0 a COUNTY OF er 0 wt rd
SEAL-S,T 11IP
W z I, `/.M tt k{ /h 0 ,a Notary Public of et rD lyuiS County of the
o m g State of Flvr:Act ,do hereby certify that CARL GOLDBERG personally came
E d before me this day and acknowledged that he/she is Managing Member of MADISON COVE
z = d s
Cn a m PROPERTIES,LLC,and acknowledged,on behalf of MADISON COVE PROPERTIES,LLC,the
> E -g grantor,the due execution of the foregoing instrument.Witness my hand and official stamp or seal,this
o n
1 day of 7641+4/ ,2021.
1'.� My Commission Expires: Q I I SV)I " V..liwtG.(' G��� Notary Public
O,y #SSP
;t rruQo VINCENi MOYER
s• Commission#GG 141250
Expires September 15,2021
6.or µ Bonded Thru Budget Notary Services

+ I
EXHIBIT"A"
LEGAL DESCRIPTION
BEING KNOWN AND DESIGNATED as Lots Nos. 16, 17, 18, 19, 20, 21,
22 and 23, Section #1 of the T.D. Preston Property, according to Plat
recorded in Book 108, Page 169 1/2 in the Office of the Register of Deeds of
Stokes County, North Carolina, to which reference is hereunto made for
certainty of description.
PROPERTY ADDRESS: 1539 NC 65 HWY. W. WALNUT COVE, NC 27052
PARCEL ID#: 6952-0461-8937.000