NCG550407_Owner (Name Change)_20240129

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
.r DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NORTH CAROLINA NPDES PERMITTING
1 Environmental Quality
PERMIT NAME OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00 / / / / or NCG5 5/D/4/ J 7
1. Facility Name: a�o c�1--k- 0m 5 'oac). (Sj\e puM k, 14_cid e ii c )
II. NEW OWNER/NAME INFORMATION: RECEIVED
1. This request for a name change is a result of: CVC Vt
I JAN 2 9 2024
a. Change in ownership of property/company
b. Name change only NCDEQ/DWR/NPDES
c. Other(please explain):
2. New owner's name (name to be put on permit):
p?k.i;d Pr‘el `y,z t,J , \5 a:, C 2. p • }- ( C. .' -"--1)..v - p—S , Lk—C
3. New owner's or signing official's name and title:
(Person legally responsible for permit)
o l.0n e /
(Title)
4. Mailing address: WIli 0 An (-1,n,..1 lecA . City: 2a1.e ,S--N
State: 0 c Zip Code: ?it p L.) ) Phone: ( 01101 )tale OI - 4 a L2 1
E-mail address: ra tA),t.e :-,,' (°I(p I C_ -5• \ I Cvey,
III. FACILITY AND DISCHARGE INFORMATION
1. Will the waste stream for the facility remain the same as under the previous owner? Yes V(No D
2. Will the treatment system and discharge location remain the same? Yeses] No ❑
"No Responses"
If either or both of these questions are answered"No"then more information will be needed to review the ,.
request. Please attach documentation to describe and explain the changes to the facility activities, waste
stream, treatment process or outfall location. The Division may not be able to process the Permit
Name/Ownership Change request and may require that the new owner file a new permit application.
Q North Carolina Department of Environmental Quality I Division of Water Quality
D_E
Ji) 512 North Salisbury Street 11617 Mail Service Center I Raleigh,North Carolina 27699-1617
°j"�`�s"'.'°"v✓ 919.707.9000

NPDES Name and Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE 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)
3. Information to document facility,waste stream,treatment system or outfall changes as noted in
item III above (if appropriate)
Applicant's Certification:
I, f�, L's � � Li;- L--,SG% , attest 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 and attachments are not included, this application package will be returned as
incomplete. I understand that Permit Name/Ownership Change can only take place through action
taken by the Division of Water Resources and that no actions on my part or the part of my company
result in the automatic transfer of permit coverage.
Signature: - " %" Date: 11 i Is 12.0
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 07/2021

United States Environmental Protection A• gency Form Approved.
E PA Washington,D.C.20460 OMB No.2040-0057
Water Compliance Inspection Report Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 IN I 2 IF I 3 NCG550407 111 121 23/12/12 117 181 dr. 191 s I 201 I
211 I I I I I 1 1 1 1 1 1 I I I I I I I l I I I l 1 l l 1 1 I_ I I I I I II I H 1 I 1 r6
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA Reserved
671 1 701 I 711 1 72 1 N I 731 I 174 75� l I I l
I I I 180
Section B: Facility Data 1 I 1
Name and Location of Facility Inspected(For Industrial Users discharging to POTW,also include Entry Time/Date Permit Effective Date
POTW name and NPDES Dermit Number) 11:30AM 23/12/12 21/08/09
2684 Boggs Road
Exit Time/Date Permit Expiration Date
West Jefferson NC 28694 12:OOPM 23/12/12 25/10/31
Name(s)of Onsite Representative(s)ffitles(s)/Phone and Fax Number(s) Other Facility Data
111 Ord/, cdn6/ Jor w ' 1)0r) 0uJr ' +3
gig- ot,g - C/- t1L(.,7
Name,Address of Responsible Officialmtle/Phone and Fax Number
Contacted
Sara R Wilson,1016 Canterbury Rd Raleigh NC 27607/1t
No
Section C: Areas Evaluated During Inspection(Check only those areas evaluated)
III Permit
Section D: Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s)and Signature(s)of Inspector(s) Agency/Office/Phone and Fax Numbers Date
DocuSigned by:
Jesse Barnes DWR/WSRO WQ/336-776-9701/ 1/9/2024
�reM �o�su0
41797473D3194ED_
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
Docusigned by: 1/11/202 4
`n J� x DWR/WSRO 336-776-9695
EPA Form 3567W2(I eWINIVrrevious editions are obsolete.
Page# 1

NPDES yr/mo/day Inspection Type (Cont.) 1
NCG550407 I11 121 23/12/12 117 18 I r•
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
On December 12, 2023, Division of Water Resources (DWR) Winston-Salem Regional Office (WSRO)
staff Jesse Barnes conducted a routine compliance evaluation inspection of the single family
residence wastewater treatment system located at 2684 Boggs Rd, West Jefferson, NC 28694, in
reference to NPDES general permit NCG550000 and certificate of coverage NCG550407. Mr. David
Wilson, owner, was not present during the inspection but was available to answer questions via
phone. A review of the subject permit, records, treatment components, outfall area, operations, and
maintenance was completed. This review reflected noncompliance with the subject permit. The
determined permit violations and items of concern are listed below. Inspection findings are detailed in
the attached Water Compliance Inspection Report.
Permit Violations
1. Effluent monitoring has not been conducted. Part I, Section C. (1.) of the subject permit requires
the discharge to be monitored and analyzed annually for the listed parameters.
2. Mr. Wilson stated that chlorine tablets have not been regularly applied to the chlorinator tubes.
Part I, Section B. (1.) of the subject permit requires that the treatment system includes disinfection.
Part I, Section D. (1.) of the subject permit requires that the tablet chlorinator be inspected regularly
to ensure there is an adequate supply of tablets for continuous and proper operation.
Items of Concern
1. No records for septic tank pumping were available during the inspection. The property changed
ownership within the past three years and the septic tank has not been pumped during that time. The
date of last pumping is unknown. The septic tank must be pumped at least once every five years with
records maintained.
2. Ownership and contact information has not been provided to DWR since the property has been
sold. Please complete and submit the attached Ownership Change Form according to its instructions.
Other observations:
Mr. Wilson stated that there have not been any problems with the system since purchasing the
property. Two chlorine tablet tubes were observed on the northwestern side of the home, but the
caps were frozen on and could not be removed for inspection. Mr. Wilson stated he has located the
outfall pipe but never observed a discharge. Mr. Barnes searched the property and receiving stream
bank for the outfall pipe but was not able to locate it. The receiving stream was free of floating solids
and foam.
Page# 2

Permit: NCG550407 Owner-Facility: 2684 Boggs Road
Inspection Date: 12/12/2023 Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new ❑ ❑ • ❑
application?
Is the facility as described in the permit? 0 0 ■ Cl
#Are there any special conditions for the permit? 0 0 • 0
Is access to the plant site restricted to the general public? 0 0 • 0
Is the inspector granted access to all areas for inspection? 0 0 ■ 0
Comment: See inspection summary.
Page# 3
1

BK 0532 PG 0039
FILED Sep 09, 2021 FILED ELECTRONICALLY
AT 09:46:30 AM ASHE COUNTY NC
-I.',,
BOOK 00532 DEAETT R. ROTEN
OplieClot it START PAGE 0039 END PAGE 0041
Sep 9,2021 INSTRUMENT # 05328
EXCISE TAX $370.00
•
NORTH CAROLINA GENERAL WARRANTY DEED
Tax Lot No Parcel Identifier 12310205
Verified by County on the day of , 2021
Excise Tax: $370
Mall after recording to ...REEVES DIVENERE WRIGHT P 0 Drawer 67,West Jefferson, North Carol
ina 28694
This instrument was prepared by REEVES DIVENERE WRIGHT
Brief description for the Index 0.34 acre, Obids Township By: John B. Reeves/sm
•
THIS DEED made on this 23rd day of August , 2021 by and between
GRANTOR(S) GRANTEE(S)
WILLIAIVI MICHAEL PATE and wife, CAPITAL CITY STOW-N-GO, LLC
KAREN ROCHELL,E PATE 1016 Canterbury Road
3410 Burberry Drive Raleigh, NC 27607
Fayetteville, NC 28304
Enter in appropriate block for each party: name, address, and,if appropriate, character of entity, e,q,
corporation or partnership.
The designation Grantor(s) and Grantee(s) 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(s),for a valuable consideration paid by the Grantee(s),the receipt of which is hereby
acknowledged, has/have and by these presents does/do grant, bargain, sell and convey unto the Grantee(s) In foe
simple,all that certain lot or parcel of land situated In the City of N/A,Obids Township,Ashe County, North Carolina
and more particularly described as follows:
REEVES DIVENERE VVRIGHT -P 0 DRAWER 67,WEST JEFFERSON, NC 28694 -[phone]
submitted electronically by "Reeves Law Firm"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Ashe County Register of Deeds.

BK 0532 PG 0041
TO HAVE AND TO HOLD, the aforesaid lot or parcel of land and all privileges and appurtenances thereto
belonging to the Grantee(s) in fee simple.
And the Grantor(s)covenant(s)with the Grantee(s), that Grantor(s) is/are seized of the premises in fee simple,
has/have the right to convey the same In fee simple, that title is marketable and free and clear of all
encumbrances, and that Grantor(s)will warrant and defend the title against the lawful claims of all persons
whomsoever except for the exceptions hereinafter stated. Title to the property hereinabove described is subject to
the following exceptions:
Notwithstanding the foregoing, Grantor(s)warrant(s) and covenant(s) that there Is/are no recorded or unrecorded
rights of first refusal affecting the subject property.
IN WITNESS WHEREOF, the Grantor(s)has/have hereunto set his/her hand and seal, ori f corporate,
has/have caused this instrument to be signed in its corporate name by its duly authorized officers and Its seal to be
hereunto affixed by authority of Its Board of Directors, the day and year first above written.
Zit (SEAL)
(Corporate Name) William Michael Pate
By: QILO� 3 c, _(SEAL)
Karen Rochelle Pate
SEAL-STAMP (leave STATE OF N C , lM*bu( kounty
'/2' ma`q lift' e14),1,I, a Notary Public of the County and State aforesaid, certify that William Michael Pate
W Fg"tnd wife, Karen Rochelle Pate
� __....
CJ �QTAI? -pef onally appeared before me this day and acknowledged the execution of the
forgoing instrument.Cress my hand and official stamp or sea this )3 day of > u�(��,, 2021.
UBLA
�`
6. `1M commission expires:j91,�t-O V. 4-77—T11-14--/ — Notary Public
,",,IND CGv ,\y``
''<<I a,i ufl"
REEVES DIVENERE WRIGHT- P 0 DRAWER 67,WEST JEFFERSON, NC 28694. [phone]

OMB NO. 2502-0265 lr
A B. TYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING&URBAN DEVELOPMENT 1.0FHA 2.[]FmHA 3.11CONV.UNINS. S.QCONV.INS.
6. FILE NUMBER: 7. LOAN NUMBER:
SETTLEMENT STATEMENT 8. MORTGAGE INS CASE NUMBER:
-
C. NOTE: This form is furnished to give you a statement of actual settlement costs_ Amounts paid to and by the settlement agent are shown.
Items marked'fPOC)"were paid outside the closing;they are shown here for informational purposes and are not included in the totals.
D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
Capital City Stow n Go,LLC William Michael Pate
2684 Boggs Road
West Jefferson,NC 28694
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: I. SETTLEMENT DATE:
2684 Boggs Road Reeves DiVenere Wright
West Jefferson,NC 28694 September 8,2021
PLACE OF SETTLEMENT
202 E. Main Street/PO Drawer 67
West Jefferson,NC 28694
J.SUMMARY OF BORROWER'S TRANSACTION * K.SUMMARY OF SELLER'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER' 400. GROSS AMOUNT DUE TO SELLER:
101. Contract Sales Price 185,000.00 401. Contract Sales Price 185,000.00
102. Personal Property 402. Personal Property
103, Settlement Charges to Borrower(Line 1400) 1,173.30 403.
104. 404.
105. 405.
Adjustments For Items Paid By Seller in advance Adjustments Forltems Paid By Seller in advance
106. City/Town Taxes to 406. City/Town Taxes to
107. County Taxes 09/08/21 to 01/01/22 314.61 _407. County Taxes to
108. Assessments to 408. Assessments to
109. 409.
110. 410,
111. 411.
112. _ 412.
120. GROSS AMOUNT DUE FROM BORROWER 186,487.91 420. GROSS AMOUNT DUE TO SELLER 185,000.00
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500.REDUCTIONS IN AMOUNT DUE TO SELLER:
201. Deposit or earnest money 501. Excess Deposit(See Instructions)
202. Principal Amount of New Loan(s) 502. Settlement Charges to Seller(Line 1400) 620.00
203. Existing loan(s)taken subject to 503. Existing loan(s)taken subject to
204. 504. Payoff of first Mortgage to First Citizens Bank 86,829.86
205. 505. Payoff of second Mortgage
206. 506.
207. 507.
208. 508.
2.09. 509,
Adjustments For Items Unpaid By Seller Adjustments For Items Unpaid By Seller
210. City/Town Taxes to 510. City/Town Taxes to
211. County Taxes to 511. County Taxes 01/01/21 to 09/08/21 683.93
212. Assessments to _ 512. Assessments to
213. 513.
214. 514.
215, 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. TOTAL PAID BY/FOR BORROWER 520. TOTAL REDUCTION AMOUNT DUE SELLER 88,133.79
300. CASH AT SETTLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER:
301. GrossAmount Due From Borrower(Line 120) 186,487.91 601. Gross Amount Due To Seiler(Line 420) 185,000.00
302. Less Amount Paid By/For Borrower(Line 220) -4( ) 602. Less Reductions Due Seller(Line 520) ( 88,133.79)
303. CASH( X FROM)( TO)BORROWER 186,487.91 603. CASH( X TO) ( FROM) SELLER 96,866,21
The undersigned hereby tlpwledge(ecei t f a completed copy of pages 1&2 of this statement&any attachments referred to herein.
Borrower `, I _ -----._ e. - ------ Seller
C ital City Stow rr o,LLC William Michael Pate
1-11J0-1(3E6)RESR1,He4305.2

Page 2
L.SETTLEMENT CHARGES
700.TOTAL COMMISSION Based on Price $ @ 074 PAID FROM PAID FROM
Division of Commission(line 700)as Follows: BORROWER'S SELLER'S
701:1 to FUNOSAT FUNDSAT
702.$ to SETTLEMENT SETTLEMENT
703.Commission Paid at Settlement
704. to
800.ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Origination Fee % to
802. Loan Discount % to
803. Appraisal Fee to
804. Credit Report to
805. Lender's Inspection Fee to
806. Mortgage Ins.App.Fee to
807. Assumption Fee to
808.
809. ,
810.
811.
900.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From to @ $ /day ( days %)
902. MIP Totl ns.for LifeOfLoan for months to
903. Hazard Insurance Premium for years to
904.
905,
1000.RESERVES DEPOSITED WITH LENDER
_1001.Hazard Insurance months @ $ per month
1002.Mortgage Insurance months @ $ per month
1003. City/Town Taxes months @ $ per month
1004. County Taxes months @ $ per month
1005. Assessments months @ $ per month
1006. months chi $ per month
1007. months @ $ per month
1008. months @ $ per month
1100.TITLE CHARGES
1101. Settlement or Closing Fee to
1102. Abstract or Title Search to
1103. Title Examination to
1104. Title Insurance Binder to
1105. Document Preparation to Reeves DiVenere Wright 250.00
1106. Title search to Lisa Gwyn 100,00
1107. Attorney's Fees to Reeves DiVenere Wright 600.00
(includes above item numbers: )
1108. Title Insurance to Fidelity National Title 437.30,
(includes above item numbers: )
1109.Lender's Coverage $
1110.Owner's Coverage $
1111.
1112.
1113.
1200.GOVERNMENT RECORDING AND TRANSFER CHARGES
1201.Recording Fees: Deed $ 26.00;Mortgage $ Releases $ 26.00
1202.City/County Tax/Stamps: Deed- ;Mortgage
1203.State Tax/Stamps: Deed 370.00; Mortgage 370.00
1204. E-fide fees to Register of Deeds 10.00
1205.
1300.ADDITIONAL SETTLEMENT CHARGES
1301. Survey to
1302. Pest Inspection to
1303.
1304.
1305.
1400.TOTAL SETTLEMENT CHARGES (Enter on Lines 103,Section J and 502,Section K) 1,173.30 620.00
By signing page 1 of this statement,the signatories acknowledge receipt of a completed copy of page 2 of this two page statement.
Reeves DiVenere Wright
Settlement Agent
( /RE610716)