NCG550679_Owner (Name Change)_20220228 (2)

Qin COOPER
ELIZARETfd S. RISER.
-ce.-retOf
5. DANIEL SMITH
NORTµ CAROLINA
EmTno+unenraai Quaint'
NPDES Certificate of Coverage (CoC)
NCG55000(( OWNERSHIP CHANGE FORM
Please enter the CoC number for which the change is requested.
Certificate of Coverage
5
ll. Please provide the following for the requested hange (revised CoC).
a. Request for change is a result of (J Change in ownership of the residence!property
0 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
CoC: Sit ye
First
d. Facility name (if applicable):
e. Facility address:
f. Facility contact person:
[if -different from Owner]
Mt
-� Title
I up L ,f ,4 L L rt
Last
Permit Holder MailingAddress g
City State Zip
Phone F.mail Address -'
Address
City State Zip
First MI last
Phone F-mail Address
III. Contact person (if different from the person legally responsible for the CoC I
First
1 ille
Mailing Address
Ciri
( 1
Phone
I.ast
Ino fiterN d Enwanerrntai Quad'v 1 Deviation of water Ite-w gees
f,12 N rth5 Oepart Noah ca.na4� #649-tea
512 Worth Sakhbut s Sheer I&7 Mai `5rgv a Cerprr ! RaiekiR
W9.7O7.4000
G I 5

NCG550000 OWNERSHIP CHANGE FORM
Page 2of2
IV. Will this permitted facility continue to discharge the same volume and type of wastewater as
piti.r to this ownership or name change?
Yes
El No (please explain)
Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
AR, INCOMPLETE OR MISSING:
a This completed application is required for both facility -name change and/or facility ownership
change requests.
f' LegaI 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.
APPLICANT CERTIFICATION
I, attest that this 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 he
returned as incomplete.
Signature
212//f-�-
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
charles.weaverncdenr.gov

Prepared by: Bee
Return to: Grantee
NORTH CAROLINA
GENERAL WARRANTY DEED
adler, Willett & Lin, P.A. Excise Tax: $654.0Q
Parcel ID: 0061720
THIS DEED made this 41day of December, 2021 by and between
GRANTOR
Marit A. Nelson and Amanda Mixon (a/k/a Amanda Varnell Nelson), a married couple
2200 Pleasant Green Rd., Durham, NC 27705
If checked, the property includes the primary residence of at least one of the Grantors. (NC GS § 105-317 2)
GRANTEE
Robin Horton and Steven Horton
100 Briar Patch, Chapel Hill, NC 27516
The designation Grantor and Grantee as 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
situated in the County of Chatham, North Carolina, and more particularly described as
follows:
See EXHIBIT A attached hereto and incorporated herein by reference.

All or a portion of die properly hcrcinah ve described was acquired by Grantor hv
instrument recorded in Book 1509, Page 4)00. Chatham County Registry.
l'() 11;'\V1: .AND 1'( ) IIt )1.1) the ;ni►res:lid lot or parcel of land and all privileges and
appurtenances thereto beloi ing to the Grantee. [heir heirs, successors, and assigns, in fee
simple,
AND "1'i1F GRANTOR ('OVFNANTS 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 dear of all encumbrances, and that Grantor will warrant and
defend the title against the lawful claims of all persons whomsoever except for the
exceptions hereinaller stated.
Title to the property hereinabove described is subject to the following exceptions:
Subject to 2021 taxes, easements, conditions and restrictions of record, if any.
EN WITNESS WHEREOF, the Grantor has hereunto set their 'bands and seals, or if
corporate, has caused this instrument to be signed in its corporate name by its duly
authorized officers) the day and year acknowledged below.
[SIGNATURE AND NOTARY PAGE(S) TO FOLLOW
i

writ . Nelson
Am a axon
STATE OF NC. --
COUNTY OF
,rj} {2,. , Notary Public for the County of
Y,s„v�.� person(s)
,State of N � , certify that the following
personally appeared before me this day, each acknowledging to me that he or she
voluntarily signed the foregoing
document for the purpose stated therein and in the
capacity indicated: Marit A. Nelson and Amanda Mixon, Grantors.
Witness my hand and official stamp
or seal, this the "% day of ,seks_ i
2021.
(SEAL)
(SEAL)
wrrhlesl
Notary Public
My CommisSion
ELLEN S. LEFKOWITZ
NOTARY PUBLIC
Wake County
North Carolina
My Commission Expires Nov. 17.2025

EXHIBIT A
Lying in Baldwin Township, Chatham County, North Carolina, and being more particularly described as
follows:
BEING all of Lot No. 100, Phase 11 and III of CHATHAM SUBDIVISION, according to the plat and survey
thereof recorded in Plat Book 15, Page 63, Chatham County Registry, to which plat reference is hereby
made for a more particular description of same.
Which has the following street address: 100 Briar Patch, Chapel Hill, NC 27516
Parcel Id # 0061720