SW4210501_transfer application_20221118

UMVILM VJC UNLT
Date Received Fee Paid Permit Number
�21 osb
NC DEQ Division of Energy, Mineral and Land Resources
STATE STORMWATER:
PERMIT TRANSFER APPLICATION FORM
Pursuant to 'I 5A NCAC 02H.1045 and other applicable statues as reference within
Only complete applications packages will be accepted and reviewed. This form and the required items(with
original signatures) must be sent to the appropriate DEMLR Regional Office, which can be determined by locating
the project on the interactive online map at: http.//deg.nc.gov/contact/regional-offices.
After this application is accepted, DEMLR will conduct a compliance inspection and report any deficiencies to the
current permittee and/or the proposed permittee. Per the state stormwater rules and the state stormwater permit
conditions, the permit shall not be transferred until:
1. the current permittee resolves all non-compliance issues identified in the inspection report;
2. the current permittee negotiates a resolution with the proposed permittee (in writing and signed by both
entities. The negotiated resolution must identify the necessary actions, the responsible party(ies), and the
timelines to correct the deficiencies. The site must either be found in compliance or a copy of the
negotiated resolution must be submitted prior to the transfer of the permit.); or
3. in the case where a transfer falls under G.S. 143-214.7(c2) (see also SL 2011-256), the proposed
permittee resolves all non-compliance issues upon acquiring the permit.
Signature requirements for the named signing official(for current and proposed permittee) must meet the following:
• Corporation-a principal executive officer of at least the level of vice-president-
Limited Liability Company(LLC) -the designated manager,- (Documentation from the NC Secretary of
State or other official documentation must be provided that states the titles and positions held by the
person who signed the application (pursuant to 02H.1040) that shows they have legal authority to sign for
the LLC)
• Municipality-a ranking official or duly authorized employee;
• Partnership or limited partnership-the general partner-
Sole proprietor,
• The signature of the consultant or other agent shall be accepted on this permit transfer application only if
accompanied by a letter of authorization signed by one of the signatories noted in a-e above, as
applicable.
A. GENERAL INFORMATION
1. State Stormwater Permit Number: SW4210501 8
2. Project name: Dollar General - Burlington
Is this an updated project name from the current permit? ❑ Yes X❑ No
3. Reason for the permit transfer request:
Property beinq transferred to new ownership
ECENEa RECEIVED
DEMLR Stormwater Program
tiJF Sty `
Stormwater Permit Transfer Application Form Page 1 of 7 April 27, 2018

C. SUBMITTAL REQUIREMENTS
Please mark'Y'to confirm the items are included with this form. Please mark`Y'if previously provided. If not
applicable or not available, please mark N/A.:
Y 1. A processing fee of five hundred and five dollars ($505.00) per G.S. 143-215.3D(e)(2).
Y 2. Two hard copies (with original signatures) and one electronic copy of this completed form and the
required items.
NA 3. For proposed permittees that are corporations or LLC's, documentation from the NC Secretary of
State demonstrating that the proposed permittee is a legal and viable entity able to conduct
business in North Carolina.
Y 4. If Part B, Items 1 or 3 of this form is selected, the signed and notarized
applicable O&M agreement(s)from the proposed permittee, as required by the permit.
Y 5. Legal documentation that the property has transferred to the proposed permittee (such as a
recorded deed for the property, uncompleted development and/or common areas) or legal
documentation demonstrating that the proposed permittee is the sole claimant of the right to
engage in the permitted activity.
Y 6. If required by the permit and if the project has been built, a signed, sealed and dated certification
document from a licensed professional stating that the stormwater management system has been
inspected and that it has been built and maintained in accordance with the approved plans.
NA 7. A copy of the recorded covenants and deed restrictions, if required by the permit. If the project has
been built, documentation that the maximum allowed per lot built-upon area or the maximum
allowed total built-upon area has not been exceeded. If the project has not been built, the new
owner shall provide a signed agreement to submit final recorded deed restrictions and protective
covenants.
NA 8. If transferring under G.S. 143-214.7(c2) (i.e., Part B, Item 2 of this form is selected),
documentation verifying that 50% or more of the lots have been conveyed to individuals (not
builders). Copies of the deeds of conveyance or a chart listing the lot number, lot address,
owner's name, conveyance date and deed book and page number are acceptable.
NA 9. If transferring under G.S. 143-214.7(c5) (i.e., Part B, Item 3 of this form is selected), provide legal
documentation supporting the dissolution of the corporation or documentation supporting the
current permittee was lawfully and finally divested of title of the property.
NA 10. A copy of the lease agreement if the proposed permittee is the lessee.
NA 11. A copy of the pending sales agreement if the proposed permittee is the purchaser.
NA 12. A copy of the development agreement if the proposed permittee is the developer.
Stormwater Permit Transfer Application Form Page 3 of 7 April 27,2018

E. PROPOSED PERMITTEE INFORMATION
1. The proposed permittee is the:
X❑ Property owner(Also complete Part F.)
❑ Home Owners Association (HOA), Property Owners Association (POA), or Unit Owner Association
(UOA) (Also completO Part F.)
❑ Lessee-Attach a copy of the lease agreement. Both the lessee and the property owner will appear on
the permit as co-permittees. If the lease is terminated, responsibility for the permit reverts to the property
owner. (Also complete Parts F& G.)
❑ Purchaser-Attach a copy of the pending sales agreement. The permit will require submission of a copy
of the recorded deed after the purchase has taken place. If the purchase agreement is cancelled the
permit reverts to the property owner. (Also complete Parts F& G.)
❑ Developer-Attach a copy of the development agreement. Both the developer and the property owner
will appear on the permit as co-permittees. If the development agreement is terminated, responsibility for
the permit reverts to the property owner. (Also complete Parts F& G.)
2. Proposed permittee name (check one of the following and provide the name):
X❑ Corporation, LLC, Partnership, Municipality name: Dorothy Wilson Family Trust 3
❑ HOA/ POA/ UOA name:
❑ Sole Proprietor
3. Proposed permittee contact information:
Please be sure to provide Email.
a. Signing Official's Name: William H. Wilson, Sr,
b. Signing Official's Title: Trustee
c. Mailing Address: c/o William H. Wilson, Sr, Trustee-221 Fieldstone Drive
d. City: Burlington State: NC ZIP : 27215
e. Street Address:
City: State: ZIP :
f. Phone: [phone] Email: wwilsonsr(a-)-realtyworldtriad.com
4. If there is a Management Entity that manages the property for an HOA, POA or UOA, please provide:
Please be sure to provide Email.
a. Management Company or Business name: NA
b. Contact Name: Title:
c. Mailing Address:
d. City: State: ZIP:
e. Phone: (_) Email:
Stormwater Permit Transfer Application Form Page 5 of 7 April 27,2018

G. PROPERTY OWNER INFORMATION AND CERTIFICATION
Fill out this section only if the property owner is different from the proposed permittee. The permit will revert to
the property owner if the purchase agreement, development agreement or lease expires or is terminated.
Company Name/Organization: NA
Signing Official's Printed Name:
Signing Official's Title:
Mailing Address:
City: State: ZIP
Phone: (_) Email:
1, hereby certify that I currently own the property identified in
this permit transfer document and acknowledge that the Proposed Permittee listed in Part F will be purchasing the
property, developing the property on my behalf, and/or leasing the property from me. A copy of the purchase
agreement, development agreement or the lease agreement, which names the party responsible for the
construction and/or operation and maintenance of the stormwater system, has been provided with the permit
transfer request.
I agree to notify DEMLR within 30 days if there are any changes to the purchase, developer or lease agreements
and will submit the applicable completed and signed Permit Information Update Form, or Permit Transfer
Application Form to address these changes. As the legal property owner, I acknowledge, understand, and agree
by my signature below, that the permit will revert to me and I will be responsible for complying with the DEMLR
Stormwater permit if the property purchase, lease or developer agreement/contract is cancelled or defaults. I
understand that any individual or entity found to be in noncompliance with the provisions of the stormwater
management permit or the stormwater rules, is subject to enforcement action as set forth in NC General Statute
(NCGS) 143, Article 21.
Signature of the property owner Date: 1._ i7—'Z-
1, A s U- -Q e-kZk, a Notary Public for the State of
c>, � (`a\k ir.C, , County of do hereby certify that
�t�-k personally appeared before me this the day of
, 20 2-L and acknowledge the due execution of the forgoing instrument. Witness
my hand an fficial seal,
(Notary Seal)
Notary Signature
My commission expires Lf Let-Z?-,
'�Q,fj 1Q'� pca
�c
Stormwater Permit Transfer Application Form Page 7 of 7 April 27, 2018