WQ0041630_Application (FTSE)_20201221

Central Files: APS _ SWP
12/17/2020
Permit Number W00041630
Program Category
Non -discharge
Permit Type
Gravity Sewer Extension, Pump Stations, $ Pressure Sewer Extensions
Primary Reviewer
dean.hunkele
Coastal SWRule
Permitted Flow
4,650
Facility
Facility Name
Elderhaus Private Sewer
Location Address
Owner
Permit Tracking Slip
Status
Project Type
In review
Minor modification
Version
Permit Classification
B
Individual
Permit Contact Affiliation
Major/Minor Region
Minor Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Name Owner Type
Elderhaus Inc Non -Government
Owner Affiliation
Rick Richards
CEO
2222 S 17th St
Dates/Events Wilmington NC 28401
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective Expiration
4/24/2020 12/10/2020
Regulated Activities
Requested /Received Events
Child care facility
Additional information received
Wastewater collection
Additional information requested
Outfall
15-5t-aA ii-e)"k
Waterbody Name
Streamindex Number Current Class Subbasin

CSD
ENGINEERING
December 21, 2020
Dean Hunkele
North Carolina Department of
Environmental Quality
Division of Water Resources
127 Cardinal Drive Extension
Wilmington, North Carolina 28405
Re: Elderhaus
Private Sewer Permit Transfer (WQ 0041630)
New Hanover County
CSD Project No. 19-0481
Dear Mr. Hunkele:
Per your request, we are providing you the additional documents necessary to facilitate the transfer of the existing
private sewer permit from Elderhaus, Inc. to the current property owner, United Church Homes and Services. Enclosed
please find:
Pdf of Executed Sewer System Permit Ownership/Name Change Form (PNOCF 01-16)
Pelf of current deed of property
If you have any questions or require anything else, please feel free to contact us. Thank you for your assistance.
Sincerely,
Mike Broyhill
Encl.: As noted above
Cc: Elderhaus, Inc., United Church Homes and Services
3805 Cherry Avenue -Wilmington, NC 28403 - 910 7914441 - www.csd-engineering.com - License # C-2710 CSD
fAYY.YFFPiNA

State of North Carolina
Department of Environmental Quality
Division of Water Resources
DWR SERVER SYSTEM PERMIT OWNERSHIP/NAME CHANCE
Division of Water Resources INSTRUCTIONS FOR FORA: PNOCF 01-16
I. EXISTING PER NIJTTEE INFORMATION:
I. Pennittee's name: Elderheus. Inc.
2. Signature authority's name: Rick 12ichards per 15A M AU 02ll_.I1106 b
3. Signature authority's title: CFO
4. Pcrmittce's mailing adores 2222 South 17°i Street
City: Wilmington State: NC Lip: 28401
5. Permittce's contact information: Phone number. (918) 931-8G Fax Numbcr(_)
Email Address: rick.richarcls(<ielderhaus.com
II. APPLICANT INFORMATION:
I. ApplicanPs name: Uniled Church Homes emd Set%ices
2. Signature authority's name: Joel Shaw per 15iA_NCn(__021 .0106 b)
3. Signature authority's title: Vice President of Facilities Management
4. Applicant's mailingaddress: 100 Lconard Avenuc
City: Newton State: NC Zip: 28658-
5. Applicant's contact information: Phone number: [phone] Fax Numbcr
Finail Adclress: jshaw(ruuchas.org
6. Representative's name:
7. Representative's title:
8. Representative's contact information Phone number: (_) _ Fax Number (_)
Email Address:
III. PERMIT INFORMATION:
I. Existing permit number: W00041630 and most recent issuance date: April24 2020
2. Reason for the permit application: Change ofownership If other, attach cletsilecl explanation
3. Has the Iacility been constructed? ❑ Yes or ® No
4. Has the facility been certified per 15A Nt'M 021-._,01j (_' ❑ Yes or ® No
FORM: PNOCF01-16 Page I oft

TV.
Existing Permlttee's Certification per 15A NCAC 02T .0106(b):
I, Rick Richards. CEO of Elderhaus. Inc. 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 eaforoement 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 applicat ackage shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed SI0,000 as well s otiit es up to ! ,ODD per violation.
Signature: . iea
T Date: 12-Lll, 0Mo
Applicant's Certification per 15A NCAC 02T .010((b):
1, Joel Shaw. Vice President of Facilities Management attest that this application
(Signature Authority's name & title from Application Item 11.2&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 infomtaton
and attachments are not included, this application package will be returned to me as incomplete.
NOTE — In accordance with General Statutes )_4i-?,IMA and 141.2t5�, any person who knowingly makes any false statement,
representation, of 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 penal ' p to $25,000 per violation.
Signature: Date: 12-18-2020
FORM: PNOCF 01-16 Page 2 of 2

Book 6327 Page 708
BK: RB 6327
PG: 708 - 710
NO FEE $2s.Do
2OTOD24517
RECORDED.
NEW HANOVER COUNTY,
06130/2020
REAL ESTATE
TAMMY THEUSCH BEASLEY
i1:23:12 AM
EXTX $4400.00
REGISTER OF DEEDS
6Y: ANGELA ENGLISH
DEPUTY ELECTRONICALLY RECORDED
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax $ 4,400.00
Parcel ID #s: R04200-004-001-000
Deed prepared by: Jennifer D. Scott, Esgx., SHIPMAN & WRIGHT, LLP — No Title Exam Performed
575 Military Cutoff Rd. Ste. 106 Wilmington, NC 28405
Mail after recording to: Grantee
dC
THIS DEED made this G —day of June, 2020, by and between
GRANTOR:
GRANTEE:
ELDERHAUS, INCORPORATED
(A North Carolina Nonprofit Corporation)
And
UNITED CHURCH HOMES AND SERVICES
(A North Carolina Nonprofit Corporation)
100 Leonard Ave,
Newton, NC 28658
The designation Grantor and Grantee us used herein shall include said parties, their heirs, successors,
and assigns, and shall include singular, plural, masculine, feminine or neuter as required by context.
WITNESSETH, 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 situate in New Hanover County, North Carolina and
more particularly described as follows:
SEE ATTACHED EXHIBIT A
The property hereinabove described was acquired by Grantor by instrument recorded in: Book 6164, Page
1789, New Hanover County Registry.
submitted electronically by "Poyner Spruill LLP"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the New Hanover county Register of Deeds.

Hook 6327 Page 709
The property conveyed herein does not include the primary residence of the Grantor.
TO HAVE AND TO 1[OLD the aforesaid lot or parcel of land and all privileges and appurtenances
thereto belonging to the Grantees in fee simple.
And the Grantors covenant with the Grantees, that Grantors are seized of the premises in fee simple,
have the right to convey the same in fee simple, that title is marketable and free and clear of all
encumbrances, and that Grantors 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:
1.) Taxes for the year 2020, which are a lien, but not yet due and payable.
2.) Easements and any other facts as shown in Map Book 10, Page 9; Map Book 17, Page 27 and
Plat Book 66, Page 247, New Hanover County Registry.
IN WITNESS WHEREOF, the Grantor has caused this instrument to be signed in its company name
by its duly authorized Officer, this the day and year first above written. pr+r1r+/1r,
ELDERIIAUS,,INCORP("ATE,D 4 ` w z SEAL
z
In
Richards, Chief Executive Officer
NORTH CAROLINA, CHATHAM COUNTY:
a Notary Public of the County and State aforesaid
do hereby certify that RICK RICHARDS, Chief Executive Officer for Elderhaus, Incorporated a North
Carolina Nonprofit Corporation, personally appeared before me this day and acknowledged the due
execution of the foregoing instrument on behalf of the corporation for the purposes therein expressed.
Witness my hand and official stamp or seal, this Q6Qtt day of June, 2020.
My commission expires: l I -19- =al"?
SF,AI., STAMP
raoay L. Bass
Notary Public
New Hanover County
[ --------North Carolina
4J 6stl%1� , Notary Public

Book 6327 Page 710
EXHIBIT A
BEGINNING at the intersection of the eastern right of way line of N.C. Highway 132 (allowing 200 feet in width)
with the southern right of way line of Kings Grant Road (allowing 80 feet in width at this location), said point being
marked by an lion Pipe (set) and is situated at the south end of a 20 foot radius curve as the same is shown on
the map of Section 3, Kings Grant Subdivision, as recorded in Map Book 10 at Page 9 of the New Hanover County
Registry, said "Point of Beginning" being that same point and place of beginning as described in that certain
instrument recorded in Book 1069 at Page 800 and 801 of the aforesaid registry. Runs thence from said
beginning, as described, with and along the eastern right of way line of N. C. Highway 132 South 10 degrees 17
minutes West Three Hundred and 0/10 (300.0) feet to an Iron Pipe (found) marking the southeast comer of Tract I
and the northwest corner of Tract 2 as described in the aforesaid instrument recorded in Book 1069 at Page 800
and 801, runs thence and continuing with and along said right of way line South 10 degrees 17 minutes West Two
Hundred Thirtyfour and 3/10 (234.3) feet to an Iron Pipe (found) marking the southwest corner of Lot 858 of
Section 13, Kings Grant Subdivision, the same being shown on a map of record duly recorded in Map Book 17 at
Page 27 of the herein before mentioned registry; runs thence and leaving the eastern right of way line of N.C.
Highway 132, with and along the southern line of Lot 858, South 79 degrees 43 minutes East One Hundred
Twenty and OPIO (120 0) feet to an Iron Pipe (found) marking the southeast corner of said lot, said pipe being
located North 79 degrees 43 minutes West Sixty and 0/10 (60.0) feet from a concrete monument (found) situated
in the center of the cul-de-sac (60 foot radius) of West Rye Lane (allowing 60 feet in width); runs thence with and
along the right of way line of said cufde-sac, 1) North 36 degrees 31 minutes East of a chord distance of Fifty three
and 04/100 (53.04) feet to an Iron Pipe (set), 2) North 86 degrees 19 minutes East a chord distance of Forty-seven
and 97/ 100 (47.97) feet to an Iron Pipe (set), 3) South 43 degrees 26 minutes 15 seconds East, a chord distance
of Fifty-three and 89/100 (53.89) feet to an Iron Pipe (set), runs thence with and along the arc of a curve (50 foot
radius) to the left, South 48 degrees 14 minutes East a chord distance of Fifty-two and 22/100 (52.22) feet to an
Iron Pipe (set) situated at the point of tangency of the northern right of way line of West Rye Lane (allowing 60 feet
in width), runs thence with and along said northern line South 79 degrees 43 minutes East Three Hundred Twelve
and 02/100 (312.02) feet to an Iron Pipe (set) marking the intersection of the northern right of way line of said
West Rye Lane with the western right of way line of Kings Grant Road (allowing 60 feet in width at this point) (a
concrete monument marks the center line intersection), runs thence with and along the western line of said road
North 10 degrees '17 minutes East Two Hundred Thirty-four and 3110 (234.3) feet to an Iron Pipe (set) making the
point of curvature (P.C.) for a curve to the left (allowing 60 feet in width for said road at this point), runs thence with
and along the westerly right of way line of said road as the same curves in a northwesterly direction to an Iron Pipe
(set) marking the point of tangency (PT ) for the southern right of way line of said road (allowing 80 feet in width at
this point); said pipe being located North 34 degrees 43 minutes West a chord distance of Four Hundred Fifty-two
and 55/100 (452.55) feet from the preceding point (P.C-), runs thence with and along the southern right of way line
of said Kings Grant Road (80 foot width) North 79 degrees 43 minutes West Two Hundred Fifty and 0/10 (250.0)
feet to an Iron Pipe (set) marking the eastern end of a 20 foot radius curve, runs thence with and along the arc of
said curve, as the same curves to the left, to the `Point of Beginning'; said point being located South 55 degrees
17 minutes West a chord distance of Twenty eight and 28/100 (28.28) feet from the preceding Iron Pipe.
The foregoing description being all of that property as conveyed in the herein before instrument duly recorded in
Deed Book '1069, Page 800 and Page 801; and being all the properties described in Deed Book 931, Page 302
through 304 and Deed Book 1069, Page 798 and Page 799.
Said property as described containing 6.87 acres, more or less]
Said property further &-scribed as lrIM 1. conta:mne, 299,095 sq. u.(681 acres) as shown un plat cnutled
"Recombination plat Prepared Far t-ldarbaus, fneorporatec Hlderhnuc Vntlh Carolina Lnr I Ilarntlt township \ew
Hanover County North Carolina", dated lime W. 21W9, prepared h}Marc F rilenn, PI'ofe$StOIIRI Land Snrvcyur-
Polaris Surveying PLLC and rccorded m plat Honk nn, Page z4-r, lieu HanOVer C:tHtnr)' RegiSny.