NCG550063_Owner (Name Change)_20190410

PAT MCCRORY
Gore,no,
DONALD R. VAN DER VAART
S. JAY ZIMMERMAN
Water Resources
ENVIRONMENTAL QUALITY Uirnrlo,
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCOO / / / / or NCG5.S /_()_/ D/ 0 /
1. Facility Name: '-11 o. CQSC(tcit, iY Ne655 cat 3
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
Xa. 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):
�USV1n of & d) -\ RA-4
`1,
3. New owner's or signing official's name and title: la i 1�.311(� \, `T 1 y
(Person legally responsible for permit)
UAJ19k
(Title) /l
4. Mailing address: 4-1a CCCC\,I n or City: V�jV '+�{�vM
State: -- Zip Code: �t1 , Phonn1e: (33\p ) D -I '/ (Q;�L
E-mail address: �� I 1� „qcW�11\ ,`w
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)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification: ll
I, R\IS-1--1 n RA-- any-, 9e4T , attest that this application for a
name/ownership change h been reviewed and accurate and complete to the best of
p my
knowledge. I understand that if all required parts of this application are not completed and that
if all required sup••rting information and attachments are not included, this application
package will be -turned :s i -orris ete.
I ______ --____
Signature: ltAv7Date: 1 l /30 J/XJ
THE COMPLETED APPLICATIO •ACKAGE, 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 7/2016

FILED DAVIDSON COUNTY, NC DAVID T. RICKARD, REGISTER OF DEEDS 7/14/2016
- IA.: S:29 AM BOOK 2229 PAGE 1529 - 1530 INSTRUMENT #2016000014039
Recording:$26.00 Excise Tax:$950.00 Deputy: ERECORD
Nec71550043
RECEIVED/NCDEQ/DWR
DEC 0 2 2016
Water Quality
Permitting Section
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: S950.00
Parcel Identifier No.01028G0000279 Verified by County on the_day of ,20_
By:
Mail to: Wyatt Early Harris, Wheeler, LLP 1912 Eastchester Drive, Suite 400,High Point,NC 27265
This instrument was prepared by: Wyatt Early Harris&Wheeler L.L.P. (R.Bruce Laney)
Brief description for the Indg : Lots 279&280 Willow Creek Subdivision, Map 7
THIS DEED made this 7 day of June,2016,by and between
GRANTOR GRANTEE
FARLEY P.DAVIS AUSTIN K.PETTY
AND SPOUSE, AND SPOUSE, •
SHARON L.DAVIS SARAH E.PETTY
41 Cumberland Street 412 Cascade Drive
Ocean Isle Beach,North Carolina 28469 High Point,North Carolina 27265
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 City of High Point,Abbotts Creek, Davidson County,North
Carolina and more particularly described as follows:
Being all of Lots 279 and 280 of Willow Creek Subdivision,Map 7 as shown on a map recorded in Plat
Book 15 at Page 18,in the Office of the Register of Deeds of Davidson County,North Carolina.
Property Address: 412 Cascade Drive,High Point,North Carolina 27265
952075
submitted electronically by "Wyatt Early Harris Wheeler LLP"
in compliance with North carolina statutes governing recordable documents
and the terms of the submitter agreement with the Davidson county Register of Deeds.

BK: 2229 PG: 1530
The property hereinabove described was acquired by Grantor by instrument recorded in Book 2029 at Page 1006.
All or a portion of the property herein conveyed X includes or does not include the primary residence of
a Grantor.
A map showing the above described property is recorded in Plat Book 15 at Page 18.
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.
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 of all persons whomsoever,other than the following
exceptions: All rights of way,easements and enforceable restrictions, if any,of record.
IN WITNESS WHEREOF,the Grantor has duly executed the foregoing as of the day and year first above written.
a-tj2 Ad--- (SEAL)
F LEY P.DAVIS
�t:4aX —u ..zi--' (SEAL)
'SHARON L.DAVIS
State of NORTH CAROLINA;County of a l/t Gl.ian
I,1)D11.sue-- u' i t.t ii e-1 , a Notary Public of the above state and county,certify FARLEY P.
DAVIS AND SPOUSE,SHARON L. DAVIS personally appeared before me this day and at the same
time and place all of the following occurred: (a)the aforesaid individual appeared in person before me;
(b)the aforesaid individual was personally known to me,or identified by my through satisfactory
evidence; and(c)the aforesaid individual either indicated and acknowledged to me that the signature on
the above document was his/hers or signed the above document while in my physical presence,and
while being personally observed by me doing so.
Witness my hand air. . otarial stamp or seal this '7 day of June, 2016.
[SEAL] ,a •' olR ' USA- . �,� ei
� NOTAR UBLIC My commission expires: Q ��
14411
%km
952075

12/15/2016 Latitude and Longitude of a Point
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