NCG551341_owner (name change)_20230721

ROY COOPER
ELIZABETH S. BISER
S. DANIEL SMITH
NORTI--I Ct�RGLINA
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 I C I G 15 1 5 1 1 131 �
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
(� 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:
biw0�.09,)*V UWwa1AK1RJ-
cftws 17v6mb U?,ATVj �
PNf� First )�6-"MI Last 00114"*Uft
cwI,
Title
URI
Permit Holder Mailing Address
CRAM N0 3
City State Zip
( L�)100 A OL I1-b 1 .3F.l l►auu�� @ Rv � �r�l
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
w - North i'orolitia Department of Envirutit itnta! Quality ! DiFisim of Watcr RC'SOUrce%
_ •� l� 517 North Salisbury Street ! 161'1' Mail Service CenteiI Raleigh, North Carolina 27093) 1017
.0000

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?
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
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.
APPL CANT CERTIFICATION
I, �st 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.
&y/0 s a ,b11i4,WA-A4A"F61x614A 7 a l c;�3
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]

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, ) do not own the property on 621 Shiloh Dr., Durham, NC 27703. This property was sold in 2020.1
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
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 OR
Land Value:
$22,455.00
null
Total Value:
$241,776.00
DURHAM , NC 27703
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 a soley the reponsibility of the user.

Book9036 - Page 630 Page 1 of 2
For Registration Sharon A. Davis
Register of Deeds
Durham County, NC
Electronically Recorded
2020 Aug 1410:53 AM
Book: 9035 Page:630
NC Rev Stamp: $ 300.00 Fee. S 26.00
Instrument Number: 2020033096
DEED
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax. $300.00
Parcel Identifier No. 158299 Verified by County on the day of , 20
This instrument was prepared by: BAGMLL 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 0 day of 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 Y.W. COPLIN Subdivision, as per plat and survey thereof now on fife 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.D0C)NC Bar Association Form No. 3 01976. Revised 0 1977.2002
Printed by Agrcornent 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.

And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee simple, has the right to convey
the same in fee simple, that title is marketable and free and clear of all encumbrances, and that Grantor will warrant and
defend the title against the lawful claims, excepting ad valorem taxes for the current year, restrictive covenants of record
affecting the property, utility easements and rights of way of record, of all persons whomsoever.
IN WITNESS WHEREOF, the Grotor has
y
�U
PuBoo,�Z.
Pursuant to N.C.G.S. §105-317.2,the
.1",
The property conveyed herein _ includes X doe
Grantors. Each Grantor's address is provided above.
Guu11e County, North Carolina
as of the day and year first above written.
J.�txi �o.lnw �au..r-, Ct
�tgj h I NC a ��13
5309 BcOrhV Dcula Ct
►Q,��T Nr zero/
(initial one) the primary residence of one or more of the
I hereby certify that the following person(s) personally appeared before me this day, each acknowledging to me
that he or she voluntarily signed the foregoing document for the purpose stated therein and in the capacity
indicated: ANDRES EDUARDO HERNANDEZ
Date:
Carolina
Printed Name of Notary
My commission expires:
Notary Public
I hereby certify that the following person(s) personally appeared before me this day, each acknowledging to me
that he or she voluntarily signed the foregoing document for the purpose stated therein and in the capacity
indicated: CYNTHIA R. HERNANDEZ
Date
.M^.....nr..-
�G CUR �.n r dtN &%. NotaryPublic
Printed Name of Notary Pubti
My commission expires: �
1000544642 spr,�ro�h* - No. 3 ® 1976, Revised ® 1977, 2002
Printed by Agee-y!Q��':++�iT Association -1981

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
Improvements Value
Township
NONE
Revenue Stamps
$300
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

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

7/20/23, 11:18 AM
Print Property Info
158299 09/22/2017
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
Depreciated Value
$118,843
CON-
Style
CONVENTIONAL
Economic Depreciation (%
0
Bad)
03-CONTINOUS-
Foundation
Functional Depreciation (%
0
SLAB
Bad)
Frame
Total Depreciated Value
$118,843
Exterior
02-BRICK
Market Area Factor
1.05
Const Type
Building Value
$94,655
05-PACKAGE-
Heating
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
Story Type
1.00 Res Frame 2Nd Flr
Building Sketch
Misc Improvements Summary
Print Property Info
Photograph
Code
FR02
No Photo Found
Area
675
Card Unit Base Eff Phys Depr (% Econ Depr (% Funct Depr (% Common Interest (%
# Quantity Measure Type Price Year Bad) Bad) Bad) Good) Value
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
Current
RIVAS, CARLOS ROBERTO LIZAMA/
WAR-WARRANTY-
QUINTANILLA, ANA JOSEFA
DEED
1 Back
HERNANDEZ, ANDRES EDURADO
QUT-QUIT-CLAIM-
DEED
2 Back
HERNANDEZ, ANDRES E/ HERNANDEZ,
WAR-WARRANTY-
MONICA
DEED
3 Back
BOWEN, TIMOTHY W/ &, TOMMY R
CONVERT-
BOWEN
CO/EFFECTIVE
Notes Summary
Building Card Date
No Data
Sale
Deed
Stamps
Book
Page
Ownership
Price
Date
100
300
$150,000 009035
00630
8/14/2020
100
0
005365
00027
9/25/2006
100
260
002412
00464
1 /21 /1998
100
0
001829
00015
1/1/1997
Line
Notes
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