NCG550025_Owner (Name Change)_20020109

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
Any changes made to this form will result in the application being returned.
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
For more information, visit our web site at: h2o.enr.state.nc.us/ndpu/
I. REQUIRED ITEMS •
I. Submit one original of the completed and appropriately executed Permit Name/Ownership Change Form. For a
change of ownership,the certification must be signed by both the current permit holder and the new applicant.
For a name change only,the certification must be signed by the applicant.
2. Provide legal documentation of the transfer of ownership(such as a contract,deed, article of incorporation,etc.)
for ownership changes. A copy of the Association Bylaws and Declarations should be submitted for a change of
ownership to a Homeowner's Association.
3. Submit a properly executed Operation and Maintenance Agreement for all Single Family Spray/Drip Irrigation
permits requesting a change of ownership.
II. CURRENT PERMIT INFORMATION •
1. Permit number: NC & 55 OOP 5 ' (Ma(9 ....JIkde..60-n
t c e)
2. Permit holder's name: s 't`rtj B we l�
3. Permit's signing official's name and title: L —81. `CeOin
(Person legally responsible for permit)
II 1� (title)
4. Mailing address: ( L2 C ( r a.S/ �RC)
City: BGk.to rS l911\'P. State: IV Zip: c 8 7 b.5
Telephone number: ( d AA ) ()r 8 4/Q Facsimile number: (
III. NEW OWNER/NAME INFORMATION --
1. This request for a permit change is a result of:
a. Change in ownership of property/company
rn
!� b Name change o`nly�� 1, l
c. Other(please explain): �
_j
FORM: PNOCF 06/00 Page 1 of 2

2. New owner's name (name to be used in permit): L a n j 8 L((If.S0 (i\
3. New owner's or signing official's name and title: Lo..l( Bur`e5 0 n
(Perso legally responsible for permit)
j�
(title)
4. Mailing address: I C�0 r'et S(.l free.k R0 c.d
Bak I� e Ks \"i t I e _ JState: II. C . Zip: oGP 70
Telephone number: (VA,fi') (age?- 6 Q Facsimile number: ( )
IV. CERTIFICATION
1. Current Permittee's Certification:
I,MOr5 Auf l eSoindeG attest that this application for 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 al] required supporting information and attachments are not included, this application
package will be returned as incomplete. I understand I will continue to be responsible for compliance with the
current permit until a new permit is issued.
Signature: Date:
2. Applicant's Certification:
I, 4.0.‘n uf'1P S bY\ , attest that this application for 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 and attachments are not included, this application
package will b returned as incomplete. .
Signature: 4 Date: I cif `6
THE COMPLETED APPLICATION PACKAGE,INCLUDING ALL SUPPORTING INFORMATION AND
MATERIALS,SHOULD BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
NON-DISCHARGE PERMITTING UNIT
By U.S.Postal Service:
1617 MAIL SERVICE CENTER 512 NORTH SALISBURY STREET,SUI'1'E 1219
RALEIGH,NORTH CAROLINA 27699-1617 RALEIGH,NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
•
FORM: PNOCF 06/00 Page 2 of 2