NCG551631_correspondence_20160511

F t�
PAT MCCRORY
Water Resources
ENVIRONMENTAL OUALIiY
Governor
1-1
DONALD R. VAN DER VAART
secretary
S. JAY ZIMMERMAN
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00 / / / / or NCG55/ 11_0 3 IL
1. Facility Name: 786 DICK He WM40 RID
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
X a. Change in ownership of property/company
b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
Ke_,VANn ps Goy.&40
3. New owner's or signing official's name and title: rb(O
Director
(Person legally responsible for p mit)
(Title)
4. Mailing address: rfaQl J \'ity: \ 1 Y rDe.A.C,C-R__,
Stag Zip Code: 3 Phone: ( 33 (4, )
E-mail address: Q �1Y1 & 6rri (")..AA1. i9,41C., CON,
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
http://portal.ncdenr.org/web/wq

Applicant's Certification: '
I,Oirwiskihic Li SCo Y , attest that this application for a
name/ownership change has bdn reviewed and is accurate and complete to the best of my
knowledge. I understand that if ail required parts of this application are not completed and that
if all required supporting information and attachments are not included, this application
package willie,returned s incompl
lti
Signature:
-.E \ ii- cool
Date: L.G -I C,o
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR 1 NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 12/2015

2;07 PM
f_ Dacuet r 7/8/2015
FILED
PersonCount
1.—.1 Russell Jones
.`AN tar Administrator
1� Issued Jai 08, 2015
"� $356.00
slit. 0f N.rtr, Cantina
P.r.sn [malty
dRuI Calais 'E ise Tea
FILED in PER5ON County, NC
.n Jul 08 20L5 at D2111I0 PM
nv E��fiANDA N. GRNETT
1112 NIJII OTO
11111111111111111111111111111
GENERAL WARRANTY DEED
Stamps: $356.00
Prepared by: C nthia T. Shriner, Attorney
Retum to: Grantee: 786 Dick Holeman Road, Timberlake, NC 27583
THIS DEED is madedtis 1?-141 day ofJuly, 2015 by and between
GRANTOR: LAURITAIt&NMELTON (widow)
GRANTEE: KELVIN L. LI$COMB, SR. and spouse
CHRISTINA M*IUUE FROST LIPSCOMB,
Tenants b}Ft Entirety
786 Dick Holemaaoad, Timberlake, NC 27583
The designation Grantor and Grantee ed herein shall include said parties, their heirs,
successors, and assigns, and shall includ ,easculine, feminine, neuter, singular or plural.
SSETH
That Grantor, for a valuable consideration pa Grantee, the receipt and sufficiency of which
is hereby acknowledged, has and by these preset: oes hereby grant, bargain, sell, and convey
unto Grantee in fee simple, all that certain lot or p el of land more particularly described as
follows:
LYING AND BEING IN FLAT RIVER TOWNSHIP, IISON COUNTY, NORTH
CAROLINA, AND BEING MORE PARTICULARLY CRIBED AS LOT NOS. 3 AND 4
ON THAT PLAT OF SURVEY ENTITLED "MAP OF E ESTATES", SURVEYED
BY C AND T SURVEYS, INC., DATED JULY 1971, AND/RECORDED IN PLAT BOOK 16,
PAGE 16, PERSON COUNTY REGISTRY, TO WHICH PLOREFERENCE IS HEREBY
MADE FOR A MORE PARTICULAR DESCRIPTION OF TEIIra$AME.
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BOOK 900 PAGE 357 360198
This conveyance DOES X or DOES NOT include the sale of Grantors' primary
�. residence.
Being ail or a portion of that property acquired by Grantor in deed recorded in Book 145, Page
cl 251, Person County Registry.
v.$A map showing the above described property is recorded in Plat Book 16, Page 16.
HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and
appurtenances thereto belonging to the Grantee in fee simple.
And mentor covenants with Grantee that Grantor is seized of the premises in fee simple, has the
right to(cbnvey the same in fee simple, that the title is marketable and free and clear of all
encumb es, and that Grantor will warrant and defend the title against the lawful claims of all
persons w soever, except for the exceptions hereinafter stated.
0
Title 10 the pi' described above is subject to the following exceptions:
-2015 ad valorea► taxes.
-All restrictions, easements, rights of way, agreements, and utilities of record.
IN WITNESS WHE
has caused this last
oRcer(s), the day and
OF, the Grantor has hereunto set his hand and seal, or if corporate,
ent to be signed in its corporate name by its duly authorized
r first above written.
LAURITAG MELTON w d v)-
STATE OF NORTH CAROLINA r)COUNTY OF
1, -1-ob;Tha'1.
State, do hereby certify that LAURITA
this day and acknowledged the due execu
Wtitis, my hand and official seal,
`�,e.;;IAA Y. Oq�!�,
izfr
TAf?
fly corgmissiorkxpirre$
(SEAL)
CnswelI
a Notary Public for said County and
MELTON (widow) personally appeared before me
of the foregoing instrumEnt.
the *h day of `] 0 Iy
t. 1
yCLUO
Public
V �roowenl;emr
onke tdaUkeproarlsekocowedrmens
scteowded or-pules
omen i +iputut4
fpri dae,ofl'ieist se8, it required.
f4mFa' a W Garrett. P - County Rem of Deeds
,2015.
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