NCG550174_Owner (Name Change)_20221103

ROY COOPER i,. ;; ,' 1
Governor r `Jd +i'
ELIZABETH S.BISER \ :'
M.an*:
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Secretary �""-�'r,�
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
NPDES Certificate of Coverage (CoC)
I NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N C ;G 5 5 19-
0 1 7 /-
II. Please provide the following for the requested change(revised CoC).
a. Request for change is a result of: 13 Change in ownership of the residence/prope
❑ 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: < Slrnrrl MI 0�/er' y
Firs( Last
©f/viiule-
C /'� / Title a
/� Permit Holder Mailing Address))
cl ►^tin 6n,n A—dv 11/6 - 7(97 y
City State Zip
( 33 0) %rf6 - .CS' 7 4.
Phone E-mail Address
d. Facility name(if applicable):
e. Facility address: 5.05d' / /f( e& Xc/
Address
WA,1/4i Ave, 27t2J
City State Zip
f. Facility contact person:
[if different from Owner] First MI Last
( )
Phone E-mail Address
III. Contact person iFditeren from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
�p Northnm of om Quality I W Re
E� 512 NorthCaroli SalisburyaDepart Street
ent 11617 Mall n Serviceental Center I RaleighDivision,Northofater Carolinasources 27699-1617
NON1H C.J 5INA v
aDw u++dEn.ewm�.\ /.4 919.707.9000

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 this ownership or name change?
Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both facility-name change and/or facility ownership
ange 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.
4--/r):(10 •v� 0Ci� �2 2c7Z2
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
-
[e-mail]

NORTH CA. OEUNA GENERAL WARRANTY DEED
EXCISE TAX: $60.00 NO TITLE SEARCH/NO CLOSING
-Parcel Identifier No. —Verified by County on the day of ,2021.
BY:
Itnail/Box to: GRANTEE{a, See Address Below
This instrument was prepared by H.Dwight Nelson,Attorney At Law P.O.Box 902,Rural Hall,NC 27045
Brief description for the index:•2 Tracts.McGee Road,Walkertown, NC
THIS DEED made this the 24th day of March,2021 by and between:
GRANTOR GRANTEE
Ell../LY,. .-J.OYCE, Executor and the Estate ,jOIINNY I AUL
Of-RUFUS• MINTEL JO • :'E• 11,
�, ; �'••: .. ..Aims
DA NIELRUFUS JOYCE JIMMY LEE OVERBY
- . .3489 Shiloh Church Road 4572 Mountain Spring Road
Winston-Salem, North Carolina 27105 Germanton,North Carolina 27105
_ J
The designation Grantor and Grantee as used herein shall included said parties,their heirs,successors,and assigns,and shall
include singular,plural,masculine,feminine or neuter as required by context.
WI'INESSETIT,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 landisituated Forsyth County,North Carolina and more
particularly described as follows:
SEE ATTACHED EXHIBIT"A"FOR FULL LEGAL DESCRIPTION
Forsyth County Tax Pin:6858-24-2955.000
PROPERTY ADDRESS: 5450.McGee Roads Walker town,North Carolina 27051r" - - - ..
As per NCGS § 105-317.2 the foiegoing:property does not include the primary residence'of the Grantor(s).
The property herein•above:described-vies acquired-by Grantor by instrument recorded,in Deed nook 1`823;Page 350'in the
Forsyth County,,Registry.• , -
The 2020-taxes have been paid in.full. • '
TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges and appurtenances
thereto belonging to the Grantee in fee simple.

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EXHIBIT"A"
TRACT# 1,
BEGINING at an iron in the West margin of McGee Road, the southeast corner of the Paul Ellis
Tract described in Deed Book 1334, Page 1022, Forsyth County Registry; thence from said
BEGINNING POINT,North 85 deg, 15 min 48 sec. West 192.27 feet to an iron in the east line
of Alene B. Gravitt,Deed Book 856, Page 27;thence with Gravitt's line,North 07 deg. 51 min.
41 sec. East 130 feet to an iron; thence South 82 deg. 16 min. 56 sec. East 191.61 Feet to an iron
in the West margin of McGee Road; thence with the margin of said road, South 07 deg. 40 min.
54 sec. West 120 feet to an iron,the point and place of BEGINNING and containing 0.5504 acre,
more or less according to a survey by Danny L. Corner on July 7th, 1981.
TRACT#2.
BEGINNING at an iron in the West margin of McGee Road, said iron lying North 07 deg, 40
min. 54 sec. East 120 feet from an iron which marks the southeast corner of the Paul Ellis tract
described in Deed Book 1334, Page 1022, Forsyth County Registry;thence from said
BEGINNING point North 82 deg, 16 min. 56 sec. West 191.61 feet to an iron in the
East line of Alene B. Gravitt, Deed Book 855,page 27;thence with Gravitt's line,North 07 deg.
51 min. 41 sec. East 120 feet to an iron,thence South 82 deg. 16 min. 56 sec. East 191.23 feet to •
an iron in the West margin of McGee Road, thence with the margin of said road, South 07 deg.
40 min. 54 sec. West 120 feet to an iron,the point and place of BEGINNING, and containing
0.5273 acre,more or less, according to a survey by Danny Corner, dated July 7, 1981.
Both Tract#1 and Tract#2 herein are conveyed subject to a 25 foot wide easement reserved by
the grantors therein, said easement running 25 feet from the parallel to the entire West side of
both parcels. This easement shall be for the purpose of access to and from the adjoining parcels
of land, and for sewer and water outfall. The grantees may not make any use of the land within
this easement which would hinder these uses of said easement. Grantors reserve the uses of this
easement in, on, over and through said 25 feet strip, and beneath the surface thereof.
Further subject to any portion of either tract which lies within the boundaries of McGee Road,
which the prior grantors have conveyed to the North Carolina Department of Transportation.