NCG550234_Owner (Name Change)_20220314

J
ROY COOPER
ore S{r`r Governor
p x . MICHAEL S. REGAN
A Secretary,
'` � j RECEIVED
S. DANIEL SMITH
:. Derec(or
`` °"' MAR 1-4 2022
NORTH CAROLINA
Environmental
onme `ol Quality NCDEQIDWRINPDES
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 0 2 3 4
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 A 4V c_w 5 klayl)e Pod(e. 1-h d►16 s /-4 4 e Pdd 16
or company name,if applicable):
c. Owner: person legally responsible for TVti '1'e c�f I �'��uS��
CoC: Pia e 6 . PGdte t' a5 -tve9 ,
First MI Last
Title
Permit Holder Mailing Address
7CQ-4 o0� � i ) ,>l
City State Zip
(,,,la ) 3 z — 3 / 521-
Phone E-mail Address
d. Facility-narr1 cif applicable)
e. Facility address:
Address
Q t�u, State Zip
f. Facility contact person: `C i/s �d�+/l
[if different from Owner] First MI Last
el First
L3L 3fS
Phone E-mail Address
III. Contact person(if different from the person legall for he CoC) a
W. Poic
ma lirsiw 5 MI Last
>AJ ,�,i /te:2-
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
Revised 12/2018

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Will thi permitted facility continue to discharge the same volume and type of wastewater as
prio o this ownership or name change?
Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
A_RWIINCOMPLETE OR MISSING:
his 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.
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 be
returned as incomplete.
/)1(1,607.60A- 11/Gt171,-04)0-36— Irt/(Ai?.(/h-- 2'o
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
Revised 4/2020

BOOK2025 PATE 305 wO 0
(.:::
Drawn by: C. D. Hogue, III, 110 West Margaret Lane, Hillsborough NC 27278
Mail to: Grantee
STATE OF NORTH CAROLINA
WARRANTY DEED
COUNTY OF ORANGE �7
THIS DEED is dated the /7 day of �, 199 '7 , and is by
and between WAYNE POOLE, unmaT7Iga, hereinafter called Grantor, and MARCUS
WAYNE POOLE, Trustee of the Mae B. Poole Trust dated December 1, 1992, LESLIE
O. WICKHAM, JR, Trustee of the Mae B. Poole Trust dated December 1, 1992, and
TEOMAS HOWARD POOLE, Trustee of the Mae B. Poole Trust dated December 1, 1992,
hereinafter called Grantee, and who has a mailing address of: g.0. Box 2715,
Ponte Vedra Beach Florida 32004.
NOW, THEREFORE, in consideration of the TEN DOLLARS and other good and
valuable consideration paid by Grantee to Grantor, the receipt of which is
hereby acknowledged, Grantor has given, bargained, sold and conveyed, and by
these presents does give, grant, bargain, sell and convey and confirm unto the
Grantee, his heirs and/or successors and assigns, premises described as
follows:
Lying and being in Cedar Grove Township, Orange County North Carolina
and consisting of 27.66 acres, more or less, designated as lot 2 on the plat
of the survey by FREEHOLD LAND SURVEYS, INC. (Stephen E. Wilson L-1370),
dated June 13, 1983, entitled - PROPERTY OF PHIL WARREN ET AL - and recorded
in Plat Book 37 at page 98 of the Orange County Registry.
49d-02-42 7s1/,
Together with a non-exclusive right in conjunction with other property owner
in the vicinity to use the 50 foot wide right-of-way for ingress egress and
regress. Maintenance of the right-of-way and other provisions regarding its
upkeep and use are provided for in a document recorded in deed book 433 at
page 270 of the Orange County Registry.
This is the same property shown on a map recorded din Plat Book 39 at page 115
of the Orange County Registry.
To have and to hold the above described premises, with all the
appurtenances thereunto belonging, or in any wise appertaining , unto the
Grantee, his heirs, successors and assigns forever.
And the Grantor covenants with the Grantee that Grantor has done nothing
to impair such title as Grantor received, and Grantor will warrant and defend
the title against the lawful claims of all persons claiming by, under or
through Grantor.
When reference is made to the Grantor or Grantee, the singular shall
include the plural and the masculine shall include the feminine or the neuter.
IN WITNESS WHERETO, the Grantor has hereunto set his hand and seal, this
the day and year first above written.
/'7d- (/Q_ (SEAL} o
AYNE� c
STATE OF NORT OLf COUNT}-OE��'�.[�-c�- u la ilac�o m
I� // jam 11 a Notary Public in and for §za€g
said County and State, ere y certify that WAYNE POOLE personally appeared
before me this day and acknowledged the due execution of the foregoing Z
instrument, for the intents and purposes therein expressed.WITNESS my hand and notarial seal,
this /9 day of Peee. r - i
uh-e-,
9�(
M All L-- a
19 commission expires: 5-/OJ ��/ -�NOTARY P
STATE OF NORTH CAROLINA, ORANGE COUNTY i4
s A�/
The foregoing certificate(%) of ex /7 ,
A Notary (er-Not.arias) Public of the designs • overnmental units is (aro) ..
cejj2tified to be correct. Filed for regis ion this the 1/,yt' day of
. , 199 9 , in record book oZ0,2S- age,�05- at ,• -._r • lock
x! zs��22ff BY.�_= -.. r I , �i.
GISTER OF DEEDS , Deputy Register . .--ds
FILED
21 DEC 1999, at 10:49:50am
Book. 2025, Page 305 - 305
Joyce H. Pearson
Register of Deeds,
Orange County, N. C.