WQ0039392_Owner (Name Change)_20190605

. .� State of North Carolina
Department of Environmental Quality
Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Dlvlsion of Warr Resources INSTRUCTIONS FOR FORM:PNOCF 01-16
I. EXISTING PERMITTEE INFORMATION:
1. Permittee's name:Hubbard Realty of Winston-Salem.Inc. ftC- D/NCDEQ/DWR
2. Signature authority's name:Bruce Hubbard per 15A NCAC 02T.0106(b) JUN 0 5 2019
3. Signature authority's title:President
Water Quality
4. Permittee's mailing address: 1598 Westbrook Plaza Drive•'Suite 200 Permitting Section
City:Winston-Salem State:NC Zip:27103-
5. Permittee's contact information: Phone number. 336 723-0303 Fax Number 336 725-6644
Email Address:bhWkmina.hubbardrealty.com
H. APPLICANT INFORMATION:
1. Applicant's name:Davidson County
2. Signature authority's name:Zeb Hanner per 15A NCAC 02T.0106(b)
3. Signature authority's title:County Manager
4. Applicant's mailing address:P.O.Box 1067
City:Lexi on State:NC_ Zip:27293-
5. Applicant's contact information: Phone number.(ID6 242- 000 Fax Number(36 249-84440
Email Address:zebhanner(a),davidsoncountync.Qov
6. Representative's name: Jerry Kennedy
7. Representative's title: Utility Technician
8. Representative's contact information Phone number: 3(�6)239-0149 Fax Number Q0 249-4178
Email Address: jerr+�kennedy@davidsonco c gov
III. PERMIT INFORMATION:
1. Existing permit number.W00039392 and most recent issuance date:8/3/17
2. .Reason for the permit application: Select If other, attach detailed explanation
3. Has the facility been constructed? ®Yes or❑No
4. Has the facility been certified per 15A NCAC 02T.0116? ®Yes or❑No
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FORM:PNOCF 01-16 Page 1 of 2

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IV. CERTIFICATIONS:
Existing Permittee's Certification per 15A NCAC 02T.0106(b):
I Bruce Hubbard, President attest that this application
(Signature Authority's name&title from Application Item 1.2&3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name,I will continue to be responsible,for compliance with the current permit and any discharge of wastewater
from this system to surface waters or the land may result in an enforcement action that may include civil penalties,injunctive relief,
and/or criminal prosecution. I will also make no claim against the Division of Water Resources should a condition ofthe existing permit
be violated. I also understand that if all required parts of this application are note completed and that if all required supporting
information and attachments are not included,this application will be returned to me as incomplete.
NOTE—In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor,which may include a fine not to
exceed$10,000 as well as civil penalties up to$25,000 per violatiQon. Q
Signature: �`""� Date-
Applicant's
,
j
Applicant's Certification per 15A NCAC 02T.0106(b):
I, Zeb Hanner, County Manager attest that this application
(Signature Authority's name&title from Application Item II.2&3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after issuance of the permit into
the Applicant's name, I will be responsible for compliance with the issued permit and any discharge of wastewater from this non-
discharge system to surface waters or the land may result in an enforcement action that may include civil penalties,injunctive relief,
and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition of this permit be violated
I also understand that if all required parts of this application package are not completed and that if all required supporting information
and attachments are not included,this application package will be returned to me as incomplete.
NOTE—In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation,or certification in any application package shall be guilty of a Class 2 misdemeanor,which may include a fine not to
exceed$10,000 as well as civil penalties up $25,000 per violation. /
Signature: Date: l Z 1
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FORM:PNOCF 01-16 Page 2 of 2

DAVIDSON COUNTY SUPPORT SERVICES DEPARTMENT
DAVIDSON COUNTY GOVERNMENTAL CENTER
P O BOX 1067
LEXINGTON NC 27293
TKCEIVED/NC0EQ/DWR
To: Debra Gore
JUN 0 5 2019
From: Davidson County
Water Quality
Date: 5-31-19 Permitting Section
RE: Change of ownership for Arcadia Ridge Subdivision, Pipers Ridge Subdivision,
Sedona Subdivision
Debra
I have enclosed 3 SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Forms. If you need any more info,please call.
THANKS
Jerry Kennedy
336-236-3120
Davidson County Support Services — 925 North Main Street— Lexington,NC 27292
Phone [phone]^- Fax [phone]