NCG551423_Owner (Name Change)_20210112

ROY COOPER
MICHAEL S. REGAN
S. DANIEL SMITH
,^nt 4
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N C G 5 5 I Li g
II. 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 /,�r Ault4lst �/or company name, if applicable): u0Y�% qro�l„ V i h4r4
c. Owner: person legally responsible for CtJqjirqf4[4
CoC: yg4i y cinq
First MI Last
RECEIVED Vrc aim
n Title d
JAN 12 2021 i o f 10q f-tuson R-o44
Permit Holder Mailing Address
NCDEQ/DWR/NPDES �Ltr4 4Oi plc �77oEf
City State Zip
(9 LS) 8)-7- gy WaJira pTe.31$1411.
Phone E-mail Address
d. Facility name(if applicable): Ya-fly4), (,s f q j Ir r,I�4l'5
e. Facility address: !0/7 Porfkaen 1 o4
Address
,Dcirl 9M K G 111e`t
City State Zip
f. Facility contact person:
[if different from Owner] First MI Last
( )
Phone E-mail Address
III. 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

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
® Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
® This completed application is required for both facility-name change and/or facility ownership
change requests.
® 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.
• APPLIC�;TCERTIFICATION
I, Y 1P?R1est tgal TIE 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.
/1 /30b. �� a
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
Ionon

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Water
♦Work'i i 1 C.P.O. Box 71333• Durham, NC 27722• [phone]• Fax[phone]•www.waterworkinc.com
NCOWCICB CERTIFIED SEPTIC INSPECTION REPORT
Report to: Yatiyana Wajirapala Phone: [phone]
1017 Patterson Road Fax:
Durham, North Carolina 27704 Email: [e-mail]
Buyer: Yatiyana Wajirapala Seller: N/A
Y Y J P
Invoice#: 20121013 Invoice Amount: $ 305.00 Requested by: Yatiyana Wajirapala Date: 12/3/20
Property Address: County: Durham
1017 Patterson Road
Durham, North Carolina 27704
House is: [] New[x] Existing [x] Occupied []Vacant Date tank was last pumped: 12/10/20 [] Unknown
Power is: [x] On [] Off Date of Inspection: 12/10/20 Percentage of sludge detected in tank: 0%
[x] Copy of operations permit from Durham County Environmental Health Department attached
[] Operations permit unavailable
The water supply for this home is furnished by[x]Well [] Community/Public Water
Type of septic system: [x] Conventional []Accepted [] Innovative [] Experimental [] Controlled Demonstration
System requires a subsurface operator[]yes[x] no If yes, copy of most recent report attached
If yes, Operator Name Operator Phone
Location of Septic Tank and Septic Tank Details: Septic tank is in the backyard west northwest of the house.*
30 ft from house or structure 133 ft from well ft from water line 124 ft from property line
1.25 ft from surface to top of tank Access riser(s) present[] yes[x] no Describe: House built in 1968.
Tank lids intact[x]yes[] no Tank has baffle wall [x]yes (half)[] no Roots present in tank[]yes[x] no
Inflow to tank is noted as[x] sufficient[] insufficient or blocked Outlet T is present[x]yes[] no Outlet has filter[]yes [x] no
Evidence of infiltration of surface water into tank []yes[x] no Evidence of tank leakage noted []yes [x] no
[] Unable to locate tank. System inspection cannot be completed until tank is located
Does system have a pump tank? []yes[x] no
ft from house or structure ft from well ft from water line ft from property line
ft from surface to top of tank Access riser(s) present[]yes[] no Describe:
ft from septic tank
Location of control panel:
Electrical connections are in place and properly grounded []yes [] no Alarm is working []yes[] no
Pump is working []yes [] no Dosing volume is correct[] yes [] no [] Unknown
Location of Drainfield: Drainfield is in the backyard west northwest of the house.**
84 ft from property line 12 ft from septic/pump tank All lines located Length of lines is 50 ft
Evidence of past or current effluent surfacing at time of inspection []yes[x] no
Large trees or other vegetation noted over drainfield area [] yes [x] no
Evidence of traffic over drainfield []yes[x] no
Pretreatment; type and description, if yes[]yes[x] no
Comments:
*Second septic tank is under the blacktop parking area.
**Distribution box lid (16.5"x 30.5") is broken and should be replaced. Line between the tank and distribution box is
orangeburg pipe as are drainlines, which appear to be filled with sand. See attached photo.
Septic tank should be pumped every 3—5 years as part of a regular maintenance program.
Inspector Name: Jim Cornwell Insp. Cert. #: 24861 Signat re: ' Date: 12/11/20
Most of the onsite wastewater system is located underground and can not be di =ct •bserv-d. T ' ' t ;r on information provided by the
requestor and on an on-site inspection,and describes the appearance of the o wastewater sys em at the tim>of inspection only. Neither WaterWork,
Inc. nor the inspector are responsible for false or misleading information provid:• by the requestor,for concealed c. ditions on the property,or for
statements in the report that resulted from false or misleading information provided to WaterWork, Inc by the requestor. No representation,warranties or
opinions are hereby given,written or expressed otherwise,as to the future perf.rmance of the onsite wastewater system described herein. This onsite
wastewater system inspection is a presentation of system facts in place on the date of inspection.

e
Permit: NCG551423 Owner-Facility: 1017 Patterson Road
• Inspection Date: 09/02/2020 Inspection Type: Complaint
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new ❑ ❑ Ii21 ❑
application?
Comment:
Is the facility as described in the permit? ❑ ❑ ❑ ❑
#Are there any special conditions for the permit? ❑ ❑ ❑ ❑
Is access to the plant site restricted to the general public? ❑ ❑ ❑ ❑
Is the inspector granted access to all areas for inspection? ❑ ❑ ❑ ❑
Comment:
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ❑ ❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable ❑ ❑ ❑ ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment:
Page# 3

Water
♦W o rk,'ft 1 V.P.O. Box 71333 • Durham, NC 27722• [phone]•Fax[phone] •www.waterworkinc.com
INVOICE
Customer Name: Yatiyana Wajirapala Address:
Property Address: 1017 Patterson Road
Durham, North Carolina 27704 Phone Number: 336-259-1407
Agent/Lender Name: Company: Phone:
INVOICE NUMBER SERVICE PERFORMED AMOUNT DUE 1
20121013 Conventional Septic System Inspection $305.00
A\ 11
TOTAL $305.00
Invoice due upon receipt.
A 5%late penalty will be added for every month beyond 30 days.
Thank you for using WaterWork, Inc. We look forward to serving you again.

6dvv1110..vvv — I (.4 1.• V I %A W.. I VI is
•
For Registration Sharon A. Davis
Register of Deeds
Durham County, NC
Electronically Recorded
2016 Aug 2912:28 PM NC Rev Stamp: $ 604.00
Book: 8008 Page: 826 Fee: $ 26.00
Instrument Number: 2016029501
DEED
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tipp$604.00
Parcel IdentifierNo..167436 Verified by County on the day of ,20
By:-
Mall/Box to:GRANTEE
-
Thiisinstrument was prepared by;Brownlee Whitlow Praet&File,PLLC,4020 WestChase Blvd.Suite.530.Raleigh:NC 27607
Brief description for the index; Lots 1,2,3,4 and 9,Property of James Ray Earp
THIS DEED made this cog day of August,2016,by and between
GRANTOR GRANTEE
Angela M:Clements:.and husband; North Carolina Buddhist Vihtara
James H Clements
Mailing Address: Property. Address;
7394 Did Lantern Drive SE 1017 Patterson Road
Caledonia,:MI 49316 Durham;NC 27704
Enter in appropriate block for each Grantor and Grantee name;mailing address,and,.if appropriate,character of entity,.e.g.
corporation or partnership.
The designation Grantor and Grantee es 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 Ole Grantee,the receipt at 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
situated in the City of Durham,Durham County,North Carolina and more:particularly described as follows:
BEING ALL OF LOTS 1,2,3,4 AND 9 OF PROPERTY OF JAME RAY EARP AND WIFE,.
LILAH H EARP,_AS PER PLAT AND SURVEY THEREOF NOW ON FILE IN THE OFFICE OF
THE REGISTER OFi DEEDS OF DURHAM COUNTY AND RECORDED IN PLAT BOOR 96,.
AT PAGE 29, TO WHICH FLAT REPERNCE. IS HEREBY MADE FOR A Mora
PARTICULAR DESCRIPTION OF SAME.
The property hereinabove,described was acquired by:Grantor by.instrument recorded in Book.6573,Page 0301.
All.or a portion of the property herein conveyed A..includes or___does-not.include the primary residence of F Grantor:
TO HOE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances thereto belonging to the
Grantee in fee simple.
submitted electronically by "Brownlee Whitlow Praet & File, PLLC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Durham County Register of Deeds.

And the Grantor covenants.With the Grantee,.that Grantor is seized of the premises in fee simple, has the right to convey the same
in fee simple,that title is marketable and free and clear of all encumbrances,and that Grantor will warrant and defend the title
against the 14411 claims of all persons whomsoever,other than the following exceptions,:
Basements,restrictions,and rights of way of record,and ad valorem taxes for the current year,if any.
IN WITNESS WHEREOF: the Grantor hasduly executed the foregoing as ofthe day and year first above written.
Angela M Clements
CB24110 •
' • Name:Angela M Clements
J es
NaMe:James H-Clements
State of N eri4A (AriVeux. -County of City OfWAKE
I,the undersigned Notary Public of the County or ay and State aforesaid, certify that Angela M Clements and husband
James H Clements personally(tame before me this day and acknowledged the dug.execution of the foregoing instrument for the
purposes therein expressed. Witness my hand and Notarial stamp or seal,this day of August 2016:
hely-Conunission Expires: 4p4 I Pt 19441 • Notary Public
(Affix Seal) BRIM 4:REGISTER a • or Typed Name
NOTARY PUBil0
Mae Couri.W
with garotina
mv comraisstoo Expires April 44,2017

Clean Septic Tank Service
5914 Jameson Rd
•
Rougemont, NC 27572 US
[phone]
[e-mail]
BILL TO INVOICE# 202642
NC Buddhist Vihara Inc DATE 12/10/2020
1017 Patterson Rd DUE DATE 12/10/2020
Durham, NC 27704 TERMS Due on receipt
;SATE AMOUNT
Septic Tank Cleaning 1 300.00- ' • �300:00
septic tank cleaning
BALANCE DUE $300.00

C (5-1 S5/ 2 g
Clean Septic Tank Service /�
5914 Jameson Rd r�'7 i✓��1i1
Rougemont, NC 27572 US seR1,G LAND seRMlce
[phone]
[e-mail]
INVOICE
BILL TO INVOICE# 202574
NC Buddhist Vihara Inc DATE 09/28/2020
1017 Patterson Rd DUE DATE 09/28/2020
Durham, NC 27704 TERMS Due on receipt
DESCRIPTION QTY RATE AMOUNT
Septic Tank Cleaning 1 300.00 300.00
septic tank cleaning
BALANCE DUE $300.00
Scanned with CamScanner

ova
SEPTIC TANK SERVICE
2600 Indian Trail • Durham, NC 27705
Durham 919-477-9073 • Chapel Hill/Hillsborough 919-967-0624
JEFF DIXON, Owner/Operator
919-291-6412 Cell
www.cleanseptictankservice.com
r o0 \ I C. "S 1 2. 3
"W
e e Want Your Stinking Business"
DESCRIPTION OF WORK
Quantity
Next
Cleaning Due
I Septic Tank Cleaning —,5C°
Effluent Filter Cleaning
Effluent Pump Tank Cleaning
Grease Trap Cleaning
Septic Pump Installed
Float Switch Installed
/ Year Supply of Bio-tab Septic Treatment
Service Call
Onsite Waste Water Inspection
Method of Payment: ❑Cash ❑Check
PO #
Acct. No.
❑ No One Home Date Completed TOTAL DOaAMOUNT y
Signature 0 Total Amount 0 Total Billing to
due for above be mailed after
Tran1 }9ou for your Business! work: or work completed.
KEEPING TANKS CLEANED FOR OVER 25 YEARS

•
2( OO Indian Trail • Durham, NC 2770
Durham 919-477-91173 • Chapel 11i11/ilillshnrough 919-967-062.1
.1 F.FF DIXON. O ner/O1>eramn•
919-291-6412 Cell
www.cleanseptictankservice.com
1• q- -3
LIP •
•
"'We Want Your Stinking Business"
DESCRIPTION OF WORK
J
Quantity Next
Cleaning Due
1 Septic Tank Cleaning
Effluent Filter Cleaning
Effluent Pump Tank Cleaning
Grease Trap Cleaning
Septic Pump Installed
• Float Switch Installed
' Year Supply of Bio-tab Septic Treatment
Service Call
• Onsite Waste Water Inspection
L'C'
Method of Payment: ❑ ash Check
Acct. No. sCL N56-
❑ No One Home Date Completed , J . 1-l$
Signature
0 Total Amount ❑ otal Billing to
due for above be mailed after
otankYou for your Business! work:or work completed.
KEEPING TANKS CLEANED FOR OVER 25 YEARS

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7,
P.O. 007. 1037
R000130, N.C. 27573
/CUSTOMER'S ORDER NO PHONE DATE
NAME
V Y AjA
ADDRESS
SOLD BY CASH C.O.D. CHARGE ON ACCT. MDSE.RET'D. PAID OUT
QTY. DESCRIPTION PRICE AMOUNT
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2 s
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TAX ZS
RECEIVED BY
TOTAL --2 s ? J 7
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c PRODUCT 610 All claims and returned goods must be accompanied by this bill.
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