wq0041721_Owner (Affiliation Change)_20211201

State of North Carolina
Department of Environmental Quality
Division of Water Resources
DWR SEWER SYSTEM PERMIT OWNERSHIPINAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
This fot-rn is for ownership changes or name changes of a sewer system permit. Please note that "Permtttec" 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-
f01.11rore tnjorVNitinrr, ViSir the Utvfsinrr s hater Qiiafity Permitting's tr 6 IrK:
A. Sewer System Permit Ownership/Name Change (FORM: PNOCF 01-16) Application (All Applications):
® Submit an original completed and appropriately executed application (PNOCF 01-16).
® The F,aisling Permittee's Certification shall be signed in accordance with 15A NCAC' 021' .0 0(b . Per k5A NCAC 02 f
.0106 c . an alternate person may be designated as the signing official if a delegation letter is provided tiom a person who
meets the critt ria in 15AN A ' 2T . 0(b J.
® The Applicant's Certification shall he signed in accordance wish 15A NCAC Per 1 SA NCAC 02T .010fi1c), an
alternate person may be dcsignated as the signing official if a delegation letter is provided from a person who meets the criteria
in I SA NC'A' 021.0 1 ON b .
R. Existing Permit (All Applications):
® Submit a copy of the most recently issued permit and certification.
C. Property Ownership Documentation (All Applications):
r The Applicant shall demonstrate they are the owneroi'all property containing the sewer system facilities-
0 Legal documentation of ownership (i e , CAS, deed, article of incorporation, or contract), or
p Writtun notarized intent to purchase agreement signed by both parties with a plat or survey map, or
Approved board minutes
D- Certificate of Public Convenience and Necessity (Alt Applications where the Applicant is a Ptivatcly-Owned Public Utility):
❑ Per 15A NCAC 02T . 11 S a 1 , provide one copy of die Certificate of Public Convenience and Necessity from the N,ort�
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non -discharge system.
F. Operational Agreements (Applications where the Applicant is a HonielProperty Ownem' Association or Developer of lots to be
sold):
r I um4/Prop cqy Own+:rs' Asxuci tilers
❑ Per 15A NCAC 02T . 115 c , submit an original properly executed Operational A •r,:cnremt FORM: FIOA .
❑ Per 15A NCAC' 02i" .0 I IS c , submit an original proposed or approved Articles of Incorporation, Declarations and By
laws that contain the tangiiage required by the Operational Agreement.
i UcyelpNr-% of lots to be.soId
❑ Per 15A NCAC 02T,01 15(h , submit an original of the property executed Operational Aura mcnLLFl) M. DL V .
Package Submitted in Duplicate
® Submit a copy of all required document~ in Instructions A-E as regiired
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED IN DUPLIC `1'E
TO:
NCDEQ - DWR
Water Quality Permitting Section
PF.RCS Unit
Br u.S. Postal Service: By Courier/Soccial. Delivery:
1617 MAIL SERVICE "..NTER it i< h, sALINRLipY ST'
11, NORTII CAROL[NA 27699-1636
L k: (.it, NORTH CAlt 1LINA 2'604
ii 0111MHER: [phone]
TION PNOC'F 01-16 Page 1 of

DWR
Division of Water Resources
1. EXISTING PERMITTEE INFORMATION:
State of North Carolina
Department of Environmental Quality
Division of Water Resources
SEWER SYSTEM PERMIT OWNERSIIIP/NAME CIIANGE
INSTRUCTIONS FOR FORM: PNOC'F 01-16
I. Pemmittee's name: Chatham Park Investors LLC
2. Signature authority's name: Timothy R. Smith per 15A NCAC 02'C .0106(b}
I Signature authority's title: Vi�c_P-Preci '
4. Pemmitlee's mailing address: 105 Wcstvn E-1ales War
City: _u State: NC Zip: 27513-
5. Permiltee's contact in formation: Phone number: (919) 481-N00 Fax Number
Email Address: rubin(ctipreslundev.cotn
II. APPLICANTINFORMATION:
1. Applicant's name: Town aCPittsbon?
2. Signature authority's name: Kent Jackson per 15A NCAC 02T .0106(bI
3. Signature authority's title: Town Entainccr
4. Applicant's mailing address: P.O. flux 759
City: Pittsbaro State: NC Zip: 27312
5. Applicant's contact information: Phone number: (939) 533-548Fax Number (__) __ -
Email Address: kjaekWn(n_niltsburonc,krov
6. Repmsenlative's name: Nicholas J_Antrilli. P.E.
7. Representative's title: Prgicet Manattcr
8_ Representative's contact information Phone number: [phone] Fax Nunmber(_)
Email Address: nantrilti �r:withetxraycncl.ce►nm
Ill. PERMIT INFORMATION:
1. Existing pennit number: WQ0041721 and most recent issuance date: Se to bcr 30.2020
2_ Reason for the permit application: Select If other. attach detailed explanation
3. I las the facility been constructed? ® Ycs or ❑ No
4. Has the facility been certified per 15A NCAC 02T .01 16? ❑ Yes or ® No
FORM: PNOCF 01-16 Page 1 of 2

IV. CERTIFICATIONS
Existing Permittce's Certification per ISA NCAC 02'T.01
I, Jjg1 hy_R._Sigh, Vic 1!mriident 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. 1 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 u condition of the existing permit
be violated. I also understand that if all required pails 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 143-215.68, any person who knowingly manes 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 S 10,000 as we s uls to 25.000 per violation. / 7
Signature: �� Date:.(� p
Applicant's Certification per ISA NC (: 02' ' 0106 h :
1, dent Jackson. Town Enginoer _ _ 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 aflcr issuance of the permit into
the Applicant's name, I will he 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 he 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 510.000 as wet as civil penalties up to $25,000 per violation. . 1
Signature:CTM Date: V N V 707vi
FORM: PNOCF U I-16 Page 2 of 2