NCG551311_Owner (Name Change)_20230831

DocuSign Envelope ID: 0OB85C33-EDF7-4DDA-98E7-D89E5D4CB2F1
ROY COOPER
Governor _ -
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR. NORTH CAROLINA
Director Environmental Quality
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
Please enter the CoC number for which the change is requested.
Certificate of Coverage
N I C I G 5 1 5 1 111
I1. Please provide the following for the requested change (revised CoC).
a. Request for change is a result of: ® 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]
ge-I1V 6- 0w�� rS
Firsi MI Last
p Title
S_7/ fp Iqo,, C,rGle
Permit Holder Mailing Address
PLI �., ti 17 71 -9,
City State Zip
(9Z0) Yea - 122s- l�rh c46-kerL'^r9r``4"(.c�..,
Phone E-mail Address
Address
t^ P­ �1 H r., V (_ 27 7 /,
City State Zip
First MI Last
Phone E-mail Address
I11. 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 Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919,707.9000
ao•mnam •i rnwaMrMr owwr

x' CbcuSign Envelope ID: 0OB85C33-EDF7-4DDA-98E7-D89E5D4CB2F1
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IV. Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
X Yes
❑ No (please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
t9 This completed application is required for both facility -name change and/or facility ownership
change requests.
10 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
I, j�v 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.
03
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
[e-mail]

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Book7915 - Page153 Page 1 of 2
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Eseise Tax
Page_
Tax Lot No.:
Verified by .
By:
For Registration W tee L Covington
Register of E*eds
Durham Cowty, NC
Ek.�ctrontcaily Recorded
2016 Apr 22 02 50 PNt NC Rev Stamp 5 0 OC
Book 7915 Pape 153 Fee 5 26.00
lnsktrnentNumber 20IW12282
DEED
S 0.00 RewrdittglbaR Book amd
Parcel Identifier No.: 1962,45
County on the day of_
Mail after recording to Kelly Gene Powers
This instrument was prepared by: Matthew S. Cheney. Attorney at Law/Brack & Gott. PLLC
Brief deseripd2! far the Index
Lots 34 and 35 in Block F of Northwood Forest, Section
5
NORTH CAROLINA SPECIAL WARRANTY DEED
THIS DEED made this 1 th day of Apfil,201 , by and between
Grantor I Grantee I
Mae aka Federal National Mortgage �:elly Gene Powers 4" sllouse ,
Address:
.O. Box 650043
iailas, TX 75265-0043 lemperty Address:
719 Paragon Circle
Notice NCGS 6105 117 2 The above inentioned pmordv is hot a adroar,resid-lIce of he r nto
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successes, and
assigns, and shall include singular, plural, masculine, feminine or neuter as required by context.
Wrl NESSET H. that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is
hereby aclatowlelged, has and by these presents dots grant, bargain, sell and convey into the Grantee m
fee simple, all that certain la or parcel of land situated in the City of Du. -ham,
Township, Durham Coucty, North Carol= and more particularly
described as follows:
Lying at Sash western intersection of Paragon Circle and Valetta Road, and being all of Lots 34 and 35
in Block F of Northwood Forest. Section 5. as per plat and survey thereof now on file in Plat Book 34 at
Page 105 in the Office of the Register of Deeds of Durham Counnty, to which plat reference is hereby
Submitted electronically by 'Brady taw Firm. PLLC"
in Compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Durham County Register of Deeds.
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Book7915 - Pagel54 Page 2 of 2
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expressly made for a more particular description of same.
Prior Grantor(s): Bemita S. Grant R'-
Property Address: 5719 Paragon Circle, Durham, NC 27�12
The property hereinabove described was acquired by the Grantor by instrument recorded in
Book 7721. Page 888, Durham County Public Register of Deeds.
A map showing the above described property is recorded in Map Book 74 Page 10.
TO HAVE AND TO HOLD the aforesaid lot or parcel or lard and all privileges and appurtenances
thereto belonging to the Grantee in fee simple.
And the Grantor covenants with the Crantoe, 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 claiming
by, under or through Grantor, except for the exceptions hereinafter stated. Title to the property
hereinabove described is subject to the following exceptions:
Easements, conditions, restrictions of record, and the 2016 Ad Valorem property taxes, a lien but
not yet due and payable.
IN WITNESS WHEREOF, the Grantor has hereunto set his hand and seal, or if corporate, bay caused this
instrument to be signed in its corporate name by its duly authorized officers and its seat to be hereunto
affixed by autbority of its Board of Directors, the day and year first above written.
Fannie ifae aka Federal National Mortmee
Aswisdoo by BROCK & SCOTP. PLLC. as
Attorney -In -Fact As Power of Attorney Recorded_
On December 20. 2013 In ]Book 28907 at Pam 1 In the
Mecldenbur>t Couety R Deeds
By:
Na r V
rate: e
STATE OF CQRTH CAROLINA
COUNTY OF MECKLENBURG
I certify that the following person personally appeared before me this day, acknowledging to me that
he/she voluntarily signed the foregoing document for .he purpose stated therein and in the capacity
indicated.
GGM= F. Ward (name of signer) as Attorney for BROCK & SCOTT. PLLC as Attorney in Fact for
Fannie Mae aka Federal Narional MortQae Association by BROCK A. SCOTf. PLLC. Attorney in Fact.
Witness my hand and notarial seal, this ___ D day of
MN% W► K BAILEYa MI)ARD I - u
tt oum ptlew •r...u. tr n.a Q txtda.d
1E OIRM. NC Name:
Ely Commission Expires: October t 2020
2016.
This nomry wkaowtedtanena mode p"nn'nt to new NCGS § 106-70. § 108 41. § 47-37 I(b). F1%cth a Deocmbes 1, 2005.
(Affix Notarial SeaUStamp)
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