WI0700031_Owner (Name Change)_20220815

North Carolina Department of Environmental Quality
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
I. INSTRUCTIONS
I. Complete this form in its entirety as follows:
(a) Change of Ownership — Provide the information in Parts II and III and submit legal documentation of the
transfer of ownership such as a contract, deed, article of incorporation, etc. The certifications in part IV
must be signed by both the current permit holder, if available, and the new applicant(s).
(b) Name Change Only — Provide the information in Parts II and III. Sign the certification for the new
applicant in part IV.2.
2. Submit the properly completed form to the address on bottom of Page 2.
II. CURRENT PERMIT INFORMATION
1. Permit Number: W I 0 7 UGO 3' l
2. Permitteename(s): 4 to:oo-Aki /36 H ( SC( fAN (14 G
3. For Business/Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
/
4. Mailing Address: C% 6i VA (a 7/ c _ Y 14 5 90 f G( p )0/'f w I y /4 k`o ov't
City: State: Zip:
Telephone number: ( ) Fax number: ( )
EMAIL Address:
5. Physical Address of Facility/Well(s) (if different than mailing address)
° I C A, wwIc ( but
City: GJ ASL tu4 T Ut\ County: 5eriu'il
Z7 ?E Y
III. NEW OWNER / NAME INFORMATION
I. This request for a permit change is a result of:
17 a. Change in ownership of property/company
b. Name change only
c. Other (please explain):
Permit/Name Change of Ownership Form Rev. 2-18-2020 Page 1

2. New Owner's name s) as listed on the property deed (Please Print/or Type):
XE 1iUo. D i X b V
Ki(lot lr. 01;x0°1
3. If Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
4. Mailing Address: ` ° ( ` & A N E ( u
State: � C Zip: 27 x 5-
City: Ll) r15 In (Af s ✓t
Day/Cell Phone No. (252)' > > - U A-00
Fax number: ( )
EMAIL Address: Do C LCO E D 1 icon tC2, I L Lu wV Cd ✓`-A
IV. CERTIFICATION
1. Current Permitts Ce ification (Please print or type):
I, C& tiN V A'c IA b' 1E , attest that this application for 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 and attachments are not included,
this application package will be returned as incomplete. I understand I will continue to be responsible for
compliance with the current permit until a new permit is issued.
2. New Applicant(s)'s certification (Please print or type):
I/We, ZQa. Cutici li-t vu L . b 1 Xprn , attest that this application for
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 and attachments are not included, this application package will be returned as incomplete. I further
certify that I will operate and maintain the permitted facility in accordance with the permit and related regulatory
requirements.
r
Signature:
Date: g/% S /Zv d3—
Signature: -��/!Date:/> /ZU L Z
SUBMIT THE COMPL APPLICATION PACKAGE VIA ONE OF TH c 6LQWING METHODS:
U.S. Postal Service:
Ground Water Resources Section
NC Division Of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
Courier / Special Delivery / In Person:
Ground Water Resources Section
NC Division Of Water Resources
512 North Salisbury Street
Raleigh, NC 27604
Telephone Number: [phone]
Permit/Name Change of Ownership Form Rev. 2-18-2020
Page 2

8/12/22, 8:04 AM
Print
jleaufort.County, NC
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Beaufort County Parcel Viewer
beaufortcountygis.com
Date Printed: 8/12/2022
GPIN:
REID1:
NAME1:
NAME2:
ADDR1:
ADDR2:
CITY:
STATE:
ZIP:
PROP_DESC:
LAND_VAL:
BLDG_VAL:
TOT_VAL:
DEFR_VAL:
TAXABLE_VAL:
PREV.ASSES:
ACRES:
PROP .ADDR:
TOWNSHIP:
MBL:
DATE:
DB_PG:
STAMPS:
SALE_PRICE:
6604-90-2908
36039
DIXON JOE W
DIXON IGM E
32244 SANDPIPER DR
32244 SANDPIPER DR
ORANGE BEACH
AL
36561
LT 85 PAMLICO PLANTATION PH -I
70005
412839
482844
0
482844
406752
1.42
101 CHANNEL RUN
05
660400321
2021-10-08
2081/00401
1210.00
605000.00
apps.agdmaps.com/print/nc/beaufort/index.html?GPIN=6604-90-2908 1/1