NCG551341_Owner (Affiliation Change)_20230725

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ry
ROY COOPER �
ELIZABETH S. RISER
Ses retarw
S.DANIEL SMITH NORTH CARO'INA
Carr€ctor Environmental Quality
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 1 3 4 1
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
21 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): CP .&i S -P—A v U r JPct P J . Quilswit.wrk
c. Owner: person legally responsible for
CoC: Cr'r►P.+ 1�-o3E1?-Th UZPtly‘ft
pw First MI Last wkrrholl
Title
loal si-int- COvAvE, 1) P 11RYY► NC 21103
Permit Holder Mailing Address
TilUettl NC, 3
City State Zip
(CIM )UCI D1— Rt.1 Jaiktuliwn@ Rv 1,004
Phone E-mail Address
d. Facility name(if applicable):
e. Facility address:
Address
City State Zip
f. Facility contact person:
[if different from Owner] First MI Last
( )
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
North Carolina Department of Environrnentat Clue+lily . Division o9 Water Resources
511 North S A hurt Street ! tbi7 Mail Service Center I R31niyh.Not th Carahna V 99 i6t
a: r� /""' 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 to this ownership or name change?
EV Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
[V]� This 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, a list 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.
/o s 75-o h tab Ad z it- eadi¢AIL O 7 - l -
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 CAROLINA DEPARTMENT OF
ENVIRONMENTAL QUALITY H11
1III11111111
'IIII IIIIIIIIIIII'II II IIII I11III I i I
INVOICE * 2 0 2 3 P R 0 0 4 4 8 8 *
Annual Permit Fee Open
This annual fee is required by the North Carolina Administrative Code. It covers the administrative costs associated
with your permit. It is required of any person holding a permit for any time during the annual fee period, regardless
of the facility's operating status. Failure to pay the fee by the due date will subject the permit to revocation.
Operating without a valid permit is a violation and is subject to a $10,000 per day fine. If the permit is revoked and
you later decide a permit is needed, you must reapply, with the understanding the permit request may be denied
due to changes in environmental, regulatory, or modeling conditions.
Invoice Number: 2023PR004488 Annual Fee Period: 2023-06-01 to 2024-05-31
Permit Number: NCG551341 Invoice Date: 05/03/2023
Durham County
621 Shiloh Drive Due Date: 06/02/2023
Andres Hernandez Annual Fee: $60.00
5309 Balmy Dawn Ct
Raleigh, NC 27613
Notes:
1. You may pay either by mail with check/money order OR by electronic payment(eCheck or Credit Card).
2. If payment is by check/money order, please remit payment to.
NCDEQ -Division of Water Resources
Attn: Animal/Discharge/Non-Discharge Billing
1617 Mail Service Center
Raleigh, NC 27699-1617
3. If payment is electronic, please see https://deq.nc.gov/epayments/wq to pay electronically. Payments by eCheck will debit your
checking account. Credit card transactions will incur a convenience fee.
4. Please include your Permit Number and Invoice Number on all correspondence.
5. A$25.00 processing fee will be charged for returned checks in accordance with North Carolina General Statute 25-3-512.
6. Non-Payment of this fee by the payment due date will initiate the permit revocation process.
7. Should you need to update any Owner/Permit/Contact information or have any questions regarding this invoice, please send
email to dwgepayAncdenr.gov or you may also contact the following:
-NPDES WW Program Administrative Contact at 919-707-3601 or
-Annual Administering and Compliance Fee Coordinator at 919-707-3698
(Return This Portion With Check)
II 11 III I III II 1 I II II I I I II I I 1 II
* 2023PR004488 *
ANNUAL PERMIT INVOICE
Open
Invoice Number: 2023PR004488 Annual Fee Period: 2023-06-01 to 2024-05-31
Permit Number: NCG551341
Durham County Invoice Date: 5/3/2023
621 Shiloh Drive Due Date: 6/2/2023
Annual Fee: $60.00
Andres Hernandez
5309 Balmy Dawn Ct
Raleigh, NC 27613 Check Number:

May 10,2023
To whom it may concern,
I have previously addressed this matter with your office,but the same mistake keeps being made.To be
clear,I do not own the property on 621 Shiloh Dr.,Durham,NC 27703.This property was sold in 2020. I
have previously notified your office about this,to no avail.
Please send this invoice to the correct owner,Carlos Lizama,who owns the property 621 Shiloh Dr.,
Durham,NC 27703.
Thank you,
Andres Hernande
5309 Balmy Dawn Court
Raleigh, NC 27613

Durham County, NC Property Report 5/18/2023
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Parcel Information
PIN: 0840-45-35-8355 Parcel ID: 158299
Acreage: 0.497 Land Use: RES/ 1-FAMILY
Deed Book: 009035 Deed Page: 000630
Plat Book: 000048 Plat Page: 000122
Subdivision: PROP-CHOPLIN T W Site Address: 621 SHILOH DR
Owner Name: RIVAS CARLOS ROBERTO LIZAMA Owner Address:621 SHILOH DR
Land Value: $22,455.00 null
DURHAM , NC 27703
Total Value: $241,776.00 Building Value: $219,321.00
Sale Price: $150,000.00
Tax Maps are not to be used to establish boundaries and/or size.Use for such is soley the reponsibility of the user.

Book9035 - Page 630 Page 1 of 2
For Registration Sharon A. Davis
Register of Deeds
Durham County, NC
Electronically Recorded
2020 Aug 14 10:53 AM
Book: 9035 Page: 630
NC Rev Stamp: S 300 00 Fee.S 26 00
Instrument Number: 2020033096
• DEED
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $300.00
Parcel Identifier No. 168299 Verified by County on the day of ,20_
This instrument was prepared by: BAGWELL HOLT SMITH P.A.(without benefit of title examination)
Grantee's address(return to): 621 Shiloh Drive,Durham, NC 27703
THIS DEED is made this t9/''day of AA,11 ,2020,by and between
GRANTOR GRANTEE
ANDRES EDUARDO HERNANDEZ and CARLOS ROBERTO LIZAMA RIVAS and
spouse, ANA JOSEFA QUINTANILLA
CYNTHIA R HERNANDEZ
The designation Grantor and Grantee as used herein shall include said parties,their heirs,successors,and assigns,and
shall include singular,plural,masculine,feminine or neuter as required by context.
WITNESSETH, 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 land situated in the Durham County,North Carolina and more particularly described as follows:
Lying on the southern side of Shiloh Drive(formerly known as Watkins Drive),and being all of Lots 11
and 12 of T.W.COPUN Subdivision,as per plat and survey thereof now on file in Plat Book 48,Page 122
in the Office of the Register of Deeds of Durham County,to which plat reference Is hereby made for a
more particular description of same.
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.
(00054464.DOC)NC Bar Association Form No. 3 0 1976.Revised 0 1977,2002
Printed by Agreement with the NC Bar Association-1981
Submitted electronically by "Bagwell Holt Smith PA-CC"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Durham county Register of Deeds.

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7/20/23, 11:18 AM Print Property Info
Durham County Property Record Card
Property Summary
Tax Year:2023
158299 0840-45-3583 RIVAS, CARLOS ROBERTO
REID PIN Property Owner
LIZAMA;QUINTANILLA,ANA JOSEFA
Location 621 Property PROP-CHOPLIN T W/LT#11- Owner's Mailing 621 SHILOH DR
Address SHILOH DR Description 12 PL000048-000122 Address DURHAM NC 27703
Administrative Data Transfer Information Property Value
Plat Book&Page 000048-000122 Deed Date 8/14/2020 Total Appraised Land Value $22,455
Old Map# Deed Book 009035 Total Appraised Building Value $219,321
Market Area R840B Deed Page 00630 Total Appraised Misc
Township NONE Revenue Stamps $300 Improvements Value
Total Cost Value $241,776
Planning Jurisdiction DURHAM COUNTY Package Sale Date 8/14/2020
Total Appraised Value-valued By $241,776
City Package Sale Price $150,000
cost
Fire District DCFR-SD Land Sale Date
Other Exemptions
Spec District CAPITAL FINANCE Land Sale Price
Exemption Desc
Land Class RES/1-FAMILY
Use Value Deferred
History REID 1 Improvement Summary
Historic Value Deferred
History REID 2 Total Buildings 2
Total Deferred Value
Acreage 0.5 Total Units 0
Total Taxable Value $241,776
Permit Date Total Living Area 3,143
Permit# Total Gross Leasable Area 0
https://taxcama.dconc.gov/camapwa/PrintPRC.aspx?PARCELPK=55854 1/4
1

7/20/23, 11:18 AM Print Property Info
Building Summary
Card 1 621 SHILOH DR
Building Details Building Description Building Total&Improvement Details
Bldg Type RESIDENTIAL Year Built 1965 Effective Year 1965 Grade C 100%
Units 1 Additions 2 Remodeled 0 Percent Complete 100
Living Area 1727 Interior Adj 1 Story Single(1.00) Total Adjusted Replacement $159,232
(SQFT) Cost New
Number of 1.00 Other Features Physical Depreciation(/°° AV 25%
Stories Bad)
Style RAN-RANCH Depreciated Value $119,424
04-P- Economic Depreciation(% 0
Foundation FOOTING/CRWL-SP Bad)
Frame Functional Depreciation(% 0
Bad)
Exterior 02-BRICK
Total Depreciated Value $119,424
Const Type
05 PACKAGE- Market Area Factor 1.05
Heating HEAT/COOL Building Value $124,666
Air Cond Misc Improvements Value
Baths(Full) 2 Total Improvement Value $124,666
Baths(Half) 0 Assessed Land Value
Extra Fixtures 0 Assessed Total Value
Total Plumbing 6
Fixtures
Bedrooms 3
Floor
Roof Cover
Roof Type
Main Body 1727
(SQFT)
Addition Summary
Story Type Code Area
1.00 Frame Deck 16 160
1.00 Covered Porch 18 140
Building Sketch Photograph
https://taxcama.dconc.gov/camapwa/PrintPRC.aspx?PARCELPK=55854 2/4

7/20/23,11:18 AM Print Property Info
16
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II _, 158299 09/22/2017
ZO
Card 2 621 SHILOH DR
Building Details Building Description Building Total&Improvement Details
Bldg Type RESIDENTIAL Year Built 1982 Effective Year 1982 Grade C 100%
Units 1 Additions 1 Remodeled 0 Percent Complete 100
Living Area 1416 Interior Adj Total Adjusted Replacement $144,931
(SQFT) Cost New
Other Features
Number of 2.00 Physical Depreciation(%Bad) AV 18%
Stories p
De reciated Value $118,843
CON-
Style CONVENTIONAL Bad)Economic Depreciation(% 0
Foundation SLAB NTINOUS Functional Depreciation(% 0
Bad)
Frame Total Depreciated Value $118,843
Exterior 02-BRICK
Market Area Factor 1.05
Const Type Building Value $94,655
Heating 05-PACKAGE- Misc Improvements Value
HEAT/COOL
Total Improvement Value $94,655
Air Cond
Baths(Full) 1 Assessed Land Value
Baths(Half) 0 Assessed Total Value
Extra Fixtures 0
Total Plumbing 3
Fixtures
Bedrooms 1
Floor
Roof Cover
Roof Type
Main Body 741
(SQFT)
Addition Summary
https://taxcama.dconc.gov/camapwa/PrintPRC.aspx?PARCELPK=55854 3/4

7/20/23, 11:18 AM Print Property Info
Story Type Code Area
1.00 Res Frame 2Nd Fir FRO2 675
Building Sketch Photograph
No Photo Found
Misc Improvements Summary
Card Unit Base Eff Phys Depr(% Econ Depr(% Funct Depr(% Common Interest(%
# Quantity Measure Type Value
Price Year Bad) Bad) Bad) Good)
No Data
Total Misc Improvements Value Assessed:
Land Summary
Land Class:RES/1-FAMILY Deeded Acres:0.5 Calculated Acres:0.5
Zoning Soil Class Description Size Rate Size Adj.Factor Land Adjustment Land Value
RS-20 BUILDING-SITE 0.50 BY THE ACRE PRICE $30,000 1.5 $22,455
Total Land Value Assessed:$22,455
Ownership History
Owner Name Deed Type Stamps Sale Book Page Deed
Ownership Price Date
Current RIVAS,CARLOS ROBERTO LIZAMA/ WAR-WARRANTY- 100 300 $150,000 009035 00630 8/14/2020
QUINTANILLA,ANA JOSEFA DEED
1 Back HERNANDEZ,ANDRES EDURADO QUT-QUIT-CLAIM- 100 0 005365 00027 9/25/2006
DEED
2 Back HERNANDEZ,ANDRES E/HERNANDEZ, WAR-WARRANTY- 100 260 002412 00464 1/21/1998
MONICA DEED
3 Back BOWEN,TIMOTHY W/&amp;,TOMMY R CONVERT- 100 0 001829 00015 1/1/1997
BOWEN CO/EFFECTIVE
Notes Summary
Building Card Date Line Notes
No Data
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