NCG550525_Owner (Name Change)_20240514

NORTH CAROLINA
Environmental Quality
NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NPDES PERMITTING
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number:
1. Facility Name:
NC00__/__J_/_/_ or NCGS_550525
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
X b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
Josh & Brooke Robertson
3. New owner's or signing official's name and title:
(Person legally responsible for permit)
(Title)
4. Mailing address: PO BOX 1018 City: Lewisville
State: NC Zip Code: 27023 Phone: [phone]
E-mail address: [e-mail] [e-mail]
III. FACILITY AND DISCHARGE INFORMATION
1. Will the waste stream for the facility remain the same as under the previous owner? Yes ■ No ❑
2. Will the treatment system and discharge location remain the same? Yes ■ 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.
D Q
�� North Carolina Department of Environmental Quality I Division of Water Quality
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
neunrtmem d..oRmrne.,numey
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, Brooke Robertson , 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: 61. Robkqtun 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 07/2021

Book 3533 Page 1851
2020026292 00130
FORSYTH CO. NC FEE $26.00
STATE OF NC REAL ESTATE EXTX
$830.00
PRESENTED & RECORDED
06/25/2020 01:50:19 PM
LYNNE JOHNSON
REGISTER OF DEEDS
BY: ANGELA M THOMPSON
DPTY
BK: RE 3533
PG: 1851 -1853
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $830.00
PIN: 5865-93-3041.000
Mail/Box to: Grantee: 1485 Double Creek Drive, Lewisville, NC 27023
This instrument was prepared by: T. Dan Womble, Attorney at Law
Brief description for the index: 4.0643 acres +/- & easement for 1485 Double Creek Drive, Lewisville, NC 27012
THIS DEED made this Z day of . V .tl!) k-) 2020 by and between
GRANTOR
Liza Thomas Taylor and husband,
Richard Clemens Taylor
4676 Ralph Davis Rd.
Folkston, GA 31537
GRANTEE
Joshua Gray Robertson and wife,
Brooke Crocker Robertson
1485 Double Creek Drive
Lewisville, NC 27023
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 parcels of land situated in
Forsyth County, North Carolina and more particularly described as follows:
See E0ibit "A" Attached hereto.
Property address: 1485 Double Creek Drive, Lewisville, NC 27023
The property hereinabove described was acquired by Grantor by instrument recorded in Book 3388, Page 1405, Forsyth County Registry.
All or a portion of the property herein conveyed _ includes or does not include the primary residence of a Grantor.
submitted electronically by "T Dan Womble Attorney"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Forsyth county Register of Deeds.
NC Bar Association Form No. 3 © 1976, Revised © 1/1/2010
Printed by Agreement with the NC Bar Association

Book 3533 Page 1852
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: easements and restrictions of record, if any; violated
zoning ordinances, if any. 2020 taxes are to be pro -rated.
IN WITNESS WHEREOF, the Grantor has duly executed the foregoing instrument as of the day and year first above written.
(SEAL)
Li Thomas Taylor i
�1 rJt (SEAL
Richard Clemens Taylor
State of " C - County ofVC'��� 1
1, k_'�C-' WC3\i ifk1 the undersigned Notary Public of the County of aitd State
aforesaid, certify that Li Thomas Taylor an husband, Richard Clemens Taylor personally appeared before me this day and
acknowledged the due execution of the foregoing instrument for the purposes therein expressed.
Witness my hand and Notarial stamp or seal this J -3—
My Commission Expires:
(Affix Seal)
MY ANCF�q
FosYt/' irP
s gF�CoCcmr)�kismioL
ss ib
�9 � �2022
NC Bar Association Form No. 3 © 1976, Revised© 1/1/2010
Printed by Agreement with the NC Bar Association

Book 3533 Page 1853
Exhibit "A"
BEGINNING at an iron in the center line of Double Creek Road marking a northeast corner
of properly described in Deed recorded in Book 1246, Page 1516, Forsyth County, North Carolina
Registry, also known as Tax Lot 63F of Block 4432, Forsyth County/City Tax Maps as presently
constituted; thence with the northeast line of said Lot 63F the following three courses and distances:
North 400 26' 31" West 172.62 feet to an iron; North 18016' 24" West 203.68 feet to an iron and
North 4b° 1.5' 04" West (crossing an iron at 200.98 feet) 237.98 feet to a point at or near the center
line of a creek; thence with the center line of said creek the following nine courses and distances:
North 540 13' 55" West 31.62 feet to a point; North 170 26' 35" West 29.17 feet to a point; North 440
31' 03" East 43.17 feet to a point; North 310 45' 31 " East 65.50 feet to a point; North 55° 04' 00" East
62.67 feet to a point; North 50° 07' 06" West 30.10 feet to a point; North 720 10' 33" West 29.54 feet
to a point; North 29 ° 16' 17" West 19. 39 feet to a point and North 611 13' 31" East 68.39 feet to a
point; thence a new line South 510 45' 27" East (crossing an iron at 22.60 feet) 512.69 feet to a'
railroad spike in the center line of Double Creek Road; thence with said center line the following four
courses and distances: South 31 ° 05' 12" West 57.40 feet to a point; South 14' 42' 12" West 128.00
feet to an iron; South 14° 22' 0V West 187.76 feet to an iron and South 29' 1 P 46" West 92.86 feet
to the point and place of beginning, containing 4.0643 acres, more or less, as shown on map
prepared by Thomas A..Riccio, dated January 24, 1990 and being a portion of Tax Lot 122B, Block
4432, Forsyth County/City Tax Maps as presently constituted. Together with and subject to the
reservation of an non-exclusive easement of ingress and egress over a 30 foot strip of the above -
described property adjoining its southeast boundary and lying within Double Creek Road (60 foot
private drivel -and subject to all those certain easements, restrictions, covenants and' agreements set
Forth in deed recorded in Book. 1124, Page I501, Forsyth County, North Carolina Registry. Together
with a non-exclusive easement of ingress and egress over Double Creek Road (60 foot private drive)
from the *southeast corner of the above described property to the intersection of said Double Creek
Road -with Williams Road (public roadway). Granter hereby. modifies restriction no. 3 of Restrictive
Covenants recorded in Book 1124, Page 1501 as applied to the above -described property by
changing the minimum square footage requirement for a one-story dwelling from 2300 square feet.
Except as modified herein, said restrictions shall remain in full force and effect.
Address: 1485 Double Creek Drive, Lewisville, NC 27023