NCG551579_Owner (Name Change)_20210914

NC Dept of Environmental Qy,
ROY Ct.Ur-R
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- fir. •, MICHALT, S. REGAN
Raleigh RegiicvIITH
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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 $ ci
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
Ti Name change of the facility or owner
If other please explain:
b. CoC will be issued to (person's name
or company name, if applicable):
c. Owner: person legally responsible for
First MI E / ,p Last
Jga._?g 0177,51TA/1/ NCP
Permit Holder Mailing Address
c, Of," di7"/
City State Zip
(?`/)6 2.63/6 V.063 5-6 C) AL. co
Phone E-mail Address
d. Facility name (if applicable):
e. Facility address:
Address
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

°•tee` .+
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 o this ownership or name change?
Yes
' ❑ No (please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE NCOMPLETE OR MISSING:
This completed application is required for both facility-name change and/or facility ownership
CA/hange 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.
APPLCNT CERTIFICATION
I, attest ttest that this application for a name/ownership change has been reviewed and is accurate and
o rr -'
understand that d parts of this application are not
complete to the best of my knowledge. I if all regr.:re�,completed and that if all required supporting information is not included, this application package will be
returned -incomplete.
. 6 (-36 r— (9/
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

,
Durham County, NC Property Report 7/14/2021
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P. --I Information
PIN: 0814-01-26-6159 Parcel ID: 181160
Acreage: 5.072 Land Use: RES/ RURAL RESIDENTIAL
Deed Book: 008762 Deed Page: 000839
Plat Book: 000188 Plat Page: 000269
Subdivision: ENO ESTATES Site Address: 2235 UMSTEAD RD
Owner Name: WILLIFORD VICTOR L JR Owner Address: 2235 UMSTEAD RD
Land Value: $73,530.00 null
DURHAM , NC 27712
Total Value: $669,726.00
Building Value: $596,196.00
Sale Price: $780,000.00
Tax Maps are not to be used to establish boundaries and/or size. Use for such is soley the reponsibility of the user.
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