NC0071862_correspondence_20240515

North Carolina Department of Environmental Quality
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
i. INSTRUCTIONS
Complete this form in its entirety as follows:
(a) Change of Ownership —Provide the information in Parts 11 and III and submit legal documentation of the
transfer of ownership such as a contract, deed, article of incorporation, etc. The certifications in part IV
must be signed by both the current permit holder, if available, and the new applicant(s).
(b) Name Change OnIY— Provide the information in Parts II and III. Sign the certification for the new
applicant in part IV.2.
2. Submit the properly completed form to the address on bottom of Page 2,
11. CURRENT PERMIT INFORMATION
I. Permit Number: NC0071862
2. Permittee name(s): CHUCK THORNE MAGNOLIA PLACE COMMUNITY LLC
3. For Business/Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
4. Mailing Address• 7250 REDWOOD BLVD, SUITE 360
City: NOVATO State: CA Zip: 94945
Telephone number: (_650___) 549-8809_Fax number: [ j
EMAIL Address:_ chuck(n ac-inanagementcom_
5. Ph sical Address of Facility/Well(s) (if different than mailing address)
City: HENDERSONVILLE County:HENDERSON Zip: 28792
Ill. NEW OWNER/NAME INFORMATION
1. This request fora permit change is a resnit of
a. Change in ownership of property/company
x b. Name change only
c. Other (please explain):
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Pei mitlNanx: Change of Ownership Form Rev. 2-I8-2020 Page I

2. New Owner's name(s) as listed on the property deed (Please Print/or Type):
LISA WAITS, MAGNOLIA PLACE COMMUNITY
3. if Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible for permit)
4. Mailing Address: 7250 REDWOOD BLVD, STE 43
City: - NOVATO State: CA Zip: 94945
Day/Cell Phone No. (_650 ) 549-8809 Fax number:
EMAIL Address: [e-mail]
IV. CERTIFICATION
Current Permittee's Certification (Please print or type):
I, , 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 be returned as incomplete. I understand I will continue to be responsible for
compliance with the current permit until a new permit is issued.
2. New Applicant(s)'s Certification (Please print or type):
I/We, , 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 be returned as incomplete. I
further certify that I will operate and maintain the permitted facility in accordance with the permit and related
regulatory requirements.
Signature: Date:
Signature:
SUBMIT THE COMPLETE APPLICATION PACKAGE VIA ONE OF THE FOLLOWING METHODS:
U.S. Postal Service: Courier / Special Delivery / In Person:
Ground Water Resources Section Ground Water Resources Section
NC Division Of Water Resources NC Division Of Water Resources
1636 Mail Service Center 512 North Salisbury Street
Raleigh, NC 27699-1636 Raleigh, NC 27604
Telephone Number: [phone]
PerinkfName Change of Ownership Form Rev. 2-I8-2020 Page 2