WQ0042573_Change of Ownership Reqest_20221127

NC Dept of Environmental Qualit\
SEP 2 7 2022 State of North Carolina
Jlepartment of Environmental Quality
DWR
Division of Water Resources
T�alei�}t RWE�4�t k()*%�PFRMIT nVVNERSIIMNAMF C'l1ANGE
Dlvlslon of Water Resources INSTRI[TTIONS FOR FORM: PNOCF 01-16
Thi% form is for ownership changes or name changes of a Sewer system permit. Please note that "Periniltec" references the
existing permit holder, and that "Applicant" references the entitY applying for the ownership name change
Sewer permits start with to WQ or WQ(S And contain the terms sewer extension or collection system in the subject Geld. This
form should not be used for permits with NC, NCG. S%% or other types of non -sewer permits beginning with WQ,
Fm „rare rrrfir, nxrrrar. UVII rite I)rl-moa s Weolcr QuoAlt 1'c, rprrrrrr� .1 a t'I�.+rlr.
A. Newer System Permit Owncrship?Name Change (FOR:-M: PNO( F 01-16) .Application (AlI Apphcatlolu)
® Submit an orlgmal completed and :rppiopnatcly executed ippllcation (PNoCF 01-10).
® I he bmstnlg Pennlll:•c's ('rru catltlr th.tll he .igntA in dcu.oidJllcc %%'till 15A NC'AC 021 .01060) Per f SA NC::1C' 1) 2 1
). ail alternate person may he dc,Ignatcd is tht: sign nic b ol,'l,tl rf a dcleg;itwn letict m i, provided from it person who
fC1 nue[s thetIftnu-a 1 A NCM I2T 01(1h(h)-
IV 1 Ili .gpplltil;ll', C Cttllll"atlEln Shall hr slgnid In acCurtl,uteC n�tll I iA N(AL o } 1 .Ill lit+( 1; Pt:r I q;.s N('A1,' t11I 0106(t), art
alterrimc person mur- be desrgmt[s:d as the signmp uf'licra', if a delegation lever Is pru%Ided tttim .1 lie'aril who nlccls the cruet rt
ul I SA NCA(_ 1121 0106(b).
Ii Existing Pcrmit IA11 App.rcal•un.f
© strhml[ .1 copy of the molt rectntly issued perintl :and ecrOication
C. Property Ownership Documenlulion (All Applwattems)
e The Applicant shall demonslraiv they are the (inner of all properly conlainmg the ,owci system I.tcilincs
® 1 coal dtit: unlcnlatiun ul'mvlteISIli p (1 e , (.'IS- t1ceJ, arllcic of Incorporalrnt!, or contr;lct), or
❑ W rincn notarized Intent to pslrchasc agrccirct;t signed by hurl; panics with i plat ur sutvcv Map, or
❑ Approved bodrtl minutes
1) Certificate of Puhlic ('umVenience and Nceessil) (All Appllcaltom WI1cre the Applicant is a Privately -OH nod Puhlic Ut hty,.
❑ Per ! SA .M A( f 2a 9115(g1t ). provide one copy ol, Ili. if crtrficars: or Public C'omcnrcncc wid Nccc-my from [he ysvrllt
( arolt11.1 IItIIli iv.s C-4 Imoas,1011 &tnon,tratmg the Applicant Is Ailkiriird to hold the utility 16naht.e liar tltc;uc.i In he served
by the non-dtseharbc system
F Operational Agreements (Appltcahun, witert the Apphc;am 1s a 1Innit:PrupetlY IAancl,' •lssocr..tiu4 or Dcvehoper of tut, to he
sold).
lumt: I'rtlp;rta Owners` A%z>o •r;llugts
ElPer I SA NCAC 021 .OI LS(J. stthw4l .to;tn,ul,tl properly c�eculcd 0 )cr,unrll;d Atrcitirt vlt.tl 11f{Rt,JI(IJ%).
❑ Pcr I SA NCAU 1121 (11 1 %J, .uksmi' ari mmgin,d proposed or appru%•c•d Articles al Itworportliun, Declarahurls and By-
1IMS I:lat ct:ntain (he i-Inguatge rcclulnd by the Ulsrr;twmtl Agreement. J.
:- DC%elopas ul Iol> Ili he sold
p per ; )A N( A(' U2 1 ill lVig sahnrll ,ni trrrgnlal of ibc• prop¢rly e\ccutcd t 1l+cr:ltton:d .lgrccnlent_{I f Ikl%I DLV).
U. Package Suhmitled to Duplicate
0 S11b tilt .1 L!pV o, ,dl ,cqw: ed docunien[s ir1 Instruenuos A-F as tctluu•cd
TUF, ('ONPI.F1'F.1);%PI'LIC'ATIOV AND SUPPORTING DOCUMENTATION S11A1,1 BE MIRMI I -FED IN DUPI,10VIl'E
it('DEQ - r7WR
'Water Qualil► Pei ruining Section
UR(s 111111
If% I .S- Portal Ner%icc: II% Collrierlhnecial Dcli%crl
1617 MAIL SERVI( F ('P N I FIR 512 N. SALISBURV ST.
RALEIGH, NOR-r11 C'AROLINA 27699-1636 SUHT 925
RM f-I(.il, NOR I It CAROLI.NA 27607
rl LE11'11()NE, NUf11BVII: (919) $07.6300
1VS,rRUC I IONS FOR APPLIC A rION PN(!( 1 01-.h F,i!;t; : of I

DWR
pivlslon of Water Resources
1. EXISTING PFRMI'I'TEE INFORMATION
State of North Carolina
Department of Environmental Quality
Division of Water Resource%
SEWER SYS1 EM PERY11'P OWNERSI11PINAME C'IIANGF
INS'rRl'CTIONS FOR FORM. PNOCF 011-I6
1. Pernmtee's name Chatham ark Investor~ LLC
2 Signature aothurity'S name:'hlrua¢ty R Snuth per _in NC 1( 031 .I110(>tb)
1. Signature autlatrity's Idle: 1'rec-I're+[(ie.tl
4 Penmitec's mauling nddr"_.: 105 11'est,m I ,talc+ 11':n
City. Cary Sr tc: NC Zip; 27513• _
5 Permiltee's cunl:[ct infurinatiyn, Phunc number, (919) 1811-3000 1-ar Numhcr l_I
1:rnail Addres&: r(ibmigpre:+rnn[Icx tiom
IL AITLICAN I INF'ORNIATION.
I. Applican!% name, I'q q(*f i'ut.,h wo
2. Signature authority's nunuc: Kent .lac4son Per 15A N( At 021_ fll0(tl b)
3 Signature authurrty'a tills- Town Enguuer
4 A\ItPllr,rnCS matltnb address. P O flux 759
City: pitt,huru Slate: NC' tip '73 2-
5- Applicant's con'art mf'urntatwn. I hums number (9€9) 533-5480 Fax Nor-nc;,r{ —) — ---
F.nuad Address slit Ilk
b. Represcnlltive's namvc Nichulus.l, Anlrillr,
7 Rep++ scnlaltve's Lille: Proicel Manager
k. Rcprc.+cntal[vc's cnnlact Infurrnattun Phone nwnhcr (919) ZL-0362 fax Number
F.Inad Addre,s n[ttturliurr wuhersr,l+taid cum
M. PERMIT INhORMATION:
I- fxMing pent; ( number; WQ0(f42573-,Ind mulct rccrnr Nsuaru,c' d.lw: August I3, 2021
CORKFC"I'(ON T
2 Reason fur th. pent-1 application: Scic.a Ifothcr, atta. h dehriled explanaltun
1 Ilas the Gti[hty been l' w.(rgICtcd' 2 Yc til- ❑ No
4 IL-[+ the facility [wen certified Iwr I iA N( A( 021 M 14.' ❑ Yes ur ® Nu
ORM PNU('F 0l in V_,Lg: I nf2

IV. CERTIFICATIONS-.
Existing Permittee's Certification per ISA NCAC 02T ,0106(b):
I, Timothy R. Smith, Vice-president, Chatham Park Investors LLC attest that this application
(Signature Authority's name & title from Application Item L2 & 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I 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 a condition of the existing permit
be violated. I also understand that if all required parts 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 14.3-215.6A and 143-215,6U, 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 $10,000 as t?l aeivil pcup to S25,000 per violation.
Signature: Date: #XaA,�t i K1 zo LZ
Applicant's Certification per 15A NCAC 021' .0106 b :
Kent Jackson, Town Engineer _ attest that this application
(Signature Authority's name & title from Application Item 1I,2&3,)
has been reviewed by me and is accurate and complete to the best of my knowtcdgc. 1 understand that after issuance of the permit into
the Applicant's name, 1 will be 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 evil 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 be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215_(A and 14a-Z15_tp, 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 $10,000 as w 11 it penalties up to $25,000 per violation.
Signature: Date: O -
FORM: PNOCF 01-16 Page 2 of