WQ0040757_Application_20190920

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
This form is for ownership changes or name changes of a sewer system permit. Please note that "Permittee" references the
existing permit holder, and that "Applicant" references the entity applying for the ownership/name change.
Sewer permits start with a WQ or WQCS and contain the terms sewer extension or collection system in the subject field. This
form should not be used for permits with NC, NCG, SW or other types of non -sewer permits beginning with WQ.
For more information, visit the Division's Water Quality Permitting's website:
A. Sewer System Permit Ownership/Name Change (FORM: PNOCF 01-16) Application (All Applications):
E Submit an original completed and appropriately executed application (PNOCF 01-16).
[M The Existing Permittee's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T
.0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a person who
meets the criteria in 15A NCAC 02T 0106(b).
[9 The Applicant's Certification shall be signed in accordance with 15A NCAC 02T 0106(b). Per 15A NCAC 02T .0106(c), an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria
in 15ANCAC 02T.0106(b)• NC- Dep�,rirp,�rr%rat
B. Existing Permit (All Applicatiens): EnVNOninel+'ialCZuz„((y
Submit a copy of the most recently issued permit and certification. Rec: ,; `i
C. Property Ownership Documentation (All Applications): 5EP 2 6 2019
➢ The Applicant shall demonstrate they are the owner of all property containing the sewer system facilities: Winston- 5a 1e m [9 Legal documentation of ownership (i.e., GIS, deed, article of incorporation, or contract), or
ElWritten notarized intent to purchase agreement signed by both parties with a plat or survey map, or R`g c'na i C)r`ice
❑ Approved board minutes
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility):
❑ Per 15A NCAC 02T 0115(a)(0, provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non -discharge system.
E. Operational Agreements (Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to be
sold):
➢ Home/Property Owners' Associations
❑ Per 15A NCAC 02T 0115(c), submit an original properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T 0115(c), submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws that contain the language required by the Operational Agreement.
➢ Developers of lots to be sold
R Per 15A NCAC 02T 0115(b), submit an original of the properly executed Operational Agreement (FORM: DEV).
F. Package Submitted in Duplicate
Submit a copy of all required documents in Instructions A-E as required
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED IN DUPLICATE
TO:
NCDEQ-DWR
Water Quality Permitting Section
PERCS Unit
By U.S. Postal Service: By Courier/Special Delivery:
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1636 SUITE 925
RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR APPLICATION PNOCF 0 1- 16 Page 1 of I

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
I. EXISTING PERMITTEE INFORMATION
NC Dop3rtinen
1. Permittee'sname: Shugart Enterprises LLC Environmeni.al O,],iffy
Received
2. Signature authority's name: Brian D. Shugart per 15A NCAC 02T .0106(b) SEP 7 0 2019
3. Signature authority's title: Managing Member WjMton-Salem
4. Permittee's mailing address: 221 Jonestown Road Regional Office
City: Winston-Salem State: NC Zip: 27401--
5. Permittee's contact information: Phone number: 336 765-9601 Fax Number 336 765-9768
Email Address: [e-mail]
II. APPLICANT INFORMATION•
I. Applicant's name: Clayton Properties Group, Inc
2. Signature authority's name: Grow,Garrett per 15A NCAC 02T.0106(b)
3. Signature authority's title: Assistant Secretary
4. Applicant's mailing address: 221 Jonestown Road.
City: Winston-Salem State: NC Zip: 27401
5. Applicant's contact information: Phone number: 336 765-9601 Fax Number 336 765-9768
Email Address: areR@,Shuaarthomes.net
net
6. Representative's name: Greg Garrett
7. Representative's title: Assistant Secretary
8. Representative's contact information Phone number: 336) 765-9601 Fax Number [phone]
Email Address: Rreggshugarthomes.net
III. PERMIT INFORMATION•
1. Existing permit number: W00040757 and most recent issuance date: April 3, 2019
2. Reason for the permit application: Change of Ownership If other, attach detailed explanation
3. Has the facility been constructed? ® Yes or ❑ No
4. Has the facility been certified per 15A NCAC 02T .01169 ❑ Yes or ® No
FORM: PNOCF 01-16 Pagel of2

IV. CERTIFICATIONS:
Existing Permittee's Certification per 15A NCAC 02T .0106(b):
I, Brian D. Shugart, Managing Member of Shugart Entemrises LLC attest that this application
(Signature Authority's name & title from Application Item I.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 of the 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 0 well as civil ties up to $25,000 per violation.
Signature: S Date: I t qr 1 q
Applicant's Certification per 15A NCAC 02T .0106(b):
I, Greg Garrett, Assistant Secretary of Clayton Properties Properties Group, Inc. Secretary of Cla�on Properties Group Inc 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 allies p to $25,000 per violation.
Signature: ��i��� Date: IG�j
I
FORM: PNOCF 01-16 Page 2 of 2

SMKM OF NORTH CAROLINA
CQtgM OF-,,
WffMSSETH,-
1. T-lieDMtO"is.,the owner of*ocprtilittwidi lyingi IMWWML;;� upon
an , 6JAWthe Development).
I The DEVELOPER desires, to construct a wastewater collection system with Pumps,, wastewater treatment.
wsj apd/6r disposal fhe ilities (hereinafter Disposal System) � to provide 9ahftarY,&sWAg0:diSVQsII to serve
I the DbveIopznent,qws,4jd4apds.
,be COMMISSION for the issuance of a permit,pursuant 3, Tli� DO, EI,0PER has applied to, t itto-G& 14.-
215j1 to construct, maintain, and operate the Disposal S $stctn.
ivo ,
4, The DEVELOPER has created or shall, createunit ownership in said dwellings units, other improvements
afid,lazids through filingufaDeclaration .of Unit Own6rship'(hdeinafter.Ddetaratidii),pursuant to Chapter
3
Ob or 47FL of the *r*,QV4hha QeWo Statutes.
5. The DgVA40PM has p to .11 be formed at the time of filing of the
cause. to be formed cause to
Ma"be for,, IM
Declaration,
oft he State
A c�'011 sao o' C
N and business. of*
of Velopelements of the lands
De me
and improvements of collecting dues and
assessments toprovide funds for such operation, maintenance, re construction andrepair.
6. The COMMISSIONAemires to assurethat the Disposal System ot-thobevc1opment is -properly constructed,
maintained and operated in accordance with I aw and permit provisions in order to protect the qaality of the
waters of the State and thevublia interest therein
NOW, THEREFORE, in consideration of the promises and the, benefits to be derived by each of the parties
hereto„ the COMMISSION and IDEVELOPER & hereby mutually agree as follows:
L The DEVELOPER shall construct the Disposal System in accordance with the permit, and. plans, and
specifications hereafter issued and approved by the, COMMISSION, and shall thereafterproperly operate.
and maintain such systems and facilities in accordance with Applicable permit provisions andlaw.
2. The DEVELOPER shall not transfer ownership and/or control of the Disposal System to the Association
until construction has been completed in accordance with the permit and approved.plans, and tht staff of
the Division of Water Resources has inspected and approved of the facilities. In order to change the, name
of the permit holder, the I)Evn6pEk must request that the permit be reissued to the AssociAtion. The
request must include a copy of the Association Bylaws, andDeclaration.
3. The DEVELOPER shall not transfer, convey, assignor otherwise relinquish or release its, responsibility for
the operation and maintenance of its Disposal System until a permit has been reissued to the DEVELOPER's
successor.
FORM: DEV 03-19 Page I oft

I
4. The DEVELOPER AAR *"In the Ddelatation and Association the Dfoosil-SOW66aftd
appurtc thesefoqreupartvftfie common elements and shall thereafterbe pfqpeily maintained and
operated, in ennformity with laWidd the pmvlaintu nftlld��ptrfflit, f rconattooft )pftftk rep* and
mAtchftnce afidj&, �S em an I ay &A A w ifift, fid Dd tMe"n y
' i fil
the entire wastdvttaat
Out rAW 1he:V'0ie$t r
tal, State, and I" t&Wwi
shall provide in the Declastim dnd A996bWWBY-1aW9 that the`D46901 System will
orsr to �svrqjha to
reparrrrrtainta#n 01 cot jjtru 16sal maintenance 0puses,
_ Ottfie t)js#" 1 0 System, bqp4 the revarw w, iion so
the Deelakition and Asso9iAt[tm,By[ewA §hjU,_ X0
the-r' ffindi allocated for life fia'tyWdA4U`bQ­--p_4rt
Such, fW, Shall Wacpam _ Ite from.theon fne mamtenance
of the e yearlyhodget.
6. kthe-,,eyout,thelcommoitpq**d.,iillocatibii,and se A t adequate- - the constirircttoirrrepair
psi te fund are no: -f(or
ifitudlhWahce W, for 4 AQW
pq 0,m *PPOW.Aw aod�Aspcl PY&W Wd -' P _-'
meospeaMp Myer such neeswax7""..1homelhemallnuton:the-atttoutrt of auohassessments,,- and
the Dd61Aftfi6trnd By&Ws 9hidl jjM4'db that AA sbecii assessments can be made aa necessary at any
7. If:a "astevtater collection system an wastewater treatment;asfdi©r disposal nfhq _typrqvapd".,,bya#y city, town village, county, water and. sewer authorltiea,er-other unit of$otemmentshall b"dinafter become
as , :w5neces8ary to cause the
&istfij anal future WqatqWg(r of"domo be X qVW and diaeharged into said gvvernrnental
systern-andshall convey or ftusler-',asl rnuch. of . the, Disposal Sys the
& Rem-& izihgjhat it*dtild-bt ddfltftuy:to the pftftihterest and to tog p#44pi flcgmv, WOW W werxareARIF
*Assnd to entprihtovd1untar Alsw wi madc,itdc!"'ato "Ision"forth&continued
.1 proyl
PA)p er maintenance, repair and operatjon'of its Disposal & i shall provide ifi"tht
ptdtfi, thbMENTLOPER,
into votimtery'dissolutlon w4outfimthaw,49
Ags6ditifloh Bylaws that qhaA not e*r
keagsferred its said system and
facilities to idrne person, corporation or other entity acceptable to and
p"d by,the COMMISSION by the
9 liuve ggreemoqts set forth blimparagraphs 1 214- 5 6 7 and 8,,obovd lahAlIbbcohdiddho of any
COMWOR to tho-MMOPW fer'�a,Cons
p eruiif,isso&'�y-tbq #WOM maintenance, repair and
sposal System
10, A,copy ofthis: agreeinent.shaR�,e;fitp�dat-thig e�lke 'ter of0e�, in the County(iei)vherethe Decliwativais
s
Ale&a;id.itithe 2o, ceg of the secretary of -State of North Carolina with the Articles of Thebi0oration afthe
19 WTFNES9, WHEREOF, this agreement was executed in dupjicate originals, by the:duty, authorized
repres of the parties hereto on the day and year written I at indicated by each of the partiesnamed below:
FOR THE ENVIRONMENT4
MANAGEMENT COMMISSION
Director, Division of Water Resources
i
FORM. DEV 03-19 Page 2 of 2