NCG551635_owner (name change)_20180821

Water Resources w
Fnvironwmal Qualrly
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
ROY COOPER
G(ovenrnr
MICHAEL S. REGAN
Sec relrrry
LiNDA CULPEPPER
hrrerrnr Drreuor
Permit Number: NC00 1 1 1 1 or NCG5_,5 1J1 1}
1. Facility Name:
Discharging single family fa-Aily�, phase use slrr•.el address for name. X1 other facility's use the actual faciity name
2. Facility Address:
II. NEW OWNER/NAME INFORMATION:
NC Dept ofFnvironmentalQuality
1. This request for a name change is a result of:
)5--a. Change in ownership of property/company
AUG z 12018
b. Name change only
Raleigh Regional Office
c. Other (please explain):
2. New owner's name (name to be put on permit):
11 1AS
3. New ownIrsor signing official's name and title:
��'
(
?son responsible for permit)
(Title)
1 1
4. Mailing address: 6 � 13 �I 4 I [? s�
City: (AC4Ih
StateA[L Zip Code: aT7 I 2L
Phone: ( 31a ) �tQ,7-715
E-mail address: ,fGt �G.�S+
51�: C�t�t1 -�
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL 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)
[see reverse side of this page for signature requirements]
—.� Nothiog Compares-_..
State of North Carolina I Environmental Quality
1611 Mail Ser%ice C enter I Raleigh. North Carolina 27699-1611
919.707-9000

Applicant's Certification:
1, JakLa Sw-1Ae,'rS attest that this application for a
namelow ership 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: 0 Q `� Date: 9 -Q7-
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ 1 DWR 1 NPDES
1617 Mail Service Center
'31Raleigh, North Carolina 27699-1617
11 017

r
Detailed Parcels Report
Tuesday, April 24, 2018
711f�1IV.1
Tax Maps are not to be used to establish boundaries and/or
size. Use for such is solely the responsLbll.ty of the user. I' • �N
T-0 7
PIN
0826-03-20-8101
Parcel ID
187670
Acreage
0,50800000
Land Use
RES/ 1-FAMILY
Deed Book
008013
Deed Page
000314
Plat Book
000075
Plat Page
000014
Subdivision
MILTON FIRST
Site Address
6113 DELLO ST
Owner Name
SANDERS JOKYA K
Owner Address
6113 DELLO ST
DURHAM , NC 27712
Land Value
$27,144.00
Building Value
$110,071.00
Total Value
$137,215.00
Sale Price
$175,000.00

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