NCG550305_owner (name change)_20230830

ROY COOPER
Go er,m
MICHAEL S. REGAN
Secrelarp
S. DANIEL SMITH
Ulreelor
L-_.nWr6wriVnW outdily
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:.
Permit Number: NC00 /_/ / /
or NCG5 / Cal 10 l
1. Facility Name:. j.!-/ j r`e �, D ljl &
t rC":3 fiw,r Icy
II. NEW OWNER/NAME INFORMATION:
1, This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only
c. Other (please explain):
2, New owner's name (name to be� put on permit):
/
Mi C k �41 0A'
3, New owner's or signing official's name and title:
(Person lee�ally responsible for permit)
4. Mailing address: �i � �� �—
(Title)
City:144dcrfontl ✓
c �� 0
Phone: 7d) ���1 �J Cv 6
State: / l Zip Co e:
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E-mail address: / � �'-Jre7'i J
/t ka,,, , °
THIS APPLICATION PACI(AGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF
THE APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of incorporation,
or sales agreement)
[see reverse side of this page for signature requirements]
North Carolina Depaitment of Environmental Quality I Division of Water Resources
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919-707-9000

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification•
I
e attest application est that this a lication for a �
name/ownership change has been reviewed and is accurate and complete to the best of my Imowledge.
understand that if all required parts of this application are not completed and that if all required
supporting information and attachments are not included, this application package will be returned as
incomplete.
b-j
J
Signature: `, ` P Date: `��
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2020

Invoice No. 116 2 4 7 "We Appreciate Your Business"
AAA Septic Service Inc.
11 Cureton Place Phone: [phone]
Hendersonville, N.C. 28791 828-692-4013
828-966-4497
Day
Owner
Troy L. Alverson jr.
Date: ��'
Appt. Time
Quantity
Description
each
Total
r
P CASH BILL CHECK
7rkdrit Card exp
CAuthorization
Total
Amount Paid
Balance Due
Directions to property:
Realtor Information: Phone#
Fax#
Name
Address
Comments/Inspection Report
Buyer Information:
All information concerning septic system expressed or written does not constitute any
warranty. Such information is given solely as to the condition of septic system at time
of inspection or service. AAA Septic Service Inc. is not responsible for failure or any
other type of septic problems or issues after property or establishment has been left.
,