NCG550274_Permit (Issuance)_20051214

O,eCft W A T�c19Q Michael F.Easley,Governor
William G.Ross Jr.,Secretary
rNorth Carolina Department of Environment and Natural Resources
Y Alan W.Klimek,P.E.Director
Division of Water Quality
December 14,2005
David W and Janice W Fowler
3818 NC 86 South
Hillsborough,NC 27278
Subject: NPDES General Permit NCG550000
Certificate of Coverage NCG550274
David W Fowler -Residence
Formerly Moore,Jesse&Rhonda-Residence
Person County
Dear Mr. and Mrs. Fowler:
Division personnel have reviewed and approved your request to transfer coverage under the General Permit.
received on December 8,2005.
Please find enclosed the revised Certificate of Coverage. The terms and conditions contained in the General
Permit remain unchanged and in full effect. This revised Certificate of Coverage is issued under the requirements of
North Carolina General Statutes 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S.
Environmental Protection Agency.
If you have any questions,please contact the NPDES Permitting Unit at(919) 733-5083,extension 520.
Sincerely,
an W. Klimek,P.E.
�/
cc: DWQ Central Files
Raleigh Regional Office,Surface Water Protection
NPDES Unit File
On
, ae Carolina
tura!!y
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh,NC 27699-1617 Phone[phone] Customer Service
Internet: h2o.enr.state.nc.us 512 N.Salisbury St. Raleigh,NC 27604 FAX [phone] 1-877-623-6748
An Equal Opportunity/Affirmative Action Employer—50%Recycled/10%Post Consumer Paper

,
,
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG550000
CERTIFICATE OF COVERAGE No. NCG550274
TO DISCHARGE DOMESTIC WASTEWATER FROM SINGLE FAMILY RESIDENCES AND OTHER
DISCHARGES WITH SIMILAR CHARACTERISTICS UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1,other lawful standards and
regulations promulgated and adopted by the North Carolina Environmental Management Commission,and the
Federal Water Pollution Control Act,as amended,
David W Fowler
is hereby authorized to operate a domestic wastewater facility which includes a septic tank,sand filter and associated
appurtenances with the discharge of treated domestic wastewater from a facility located at
DAVID W FOWLER—RESIDENCE
581 HIDEAWAY LN
LEASBURG
PERSON COUNTY
to receiving waters designated as Hyco Lake,a class C water,in the Roanoke River Basin in accordance with the
effluent limitations,monitoring requirements,and other conditions set forth in Parts I,II,III,and IV of General
Permit No.NCG550000 as attached.
This certificate of coverage shall become effective December 14,2005.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day December 14,2005.
6la W. Klimek, P.E., Director
/ Division of Water Quality
By Authority of the Environmental Management Commission

_
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t 09%VA '� Michael F.Easley,Governor
rY O6 William G.Ross Jr.,Secretary
North Carolina Department of Environment and Natural Resources
' o t Alan W.Klimek,P.E.Director
Division of Water Quality
SURFACE WATER PROTECTION SECTION
PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N C N C G 5 O 2J7 y
II. Permit status prior to status change.
a. Permit issued to(company name):
b.Person legally responsible for permit. J e b S f' L Moo r e•
First / MI / Last
Title
V_)0) Permit Holder Marling Address
V- \ City State Zip
) ( )
Phame Fax
c. Facility name(discharge):
d.Facility address: s�fi / ee,owA; L Pt-f
Address
1.4014u.1 /uC Z72Y/
City State Zip
e. Facility contact person: ( )
First / MI / Last Phone
HI. Please provide the following for the requested change(revised permit).
a. Request for change is a result of: le Change in ownership of the facility
0 Name change of the facility or owner
If other please explain:
b.Permit issued to(company name): /V A
c. Person legally responsible for permit: Da ()IA itv -
First / MI/ Last
ner
Title
Permit Holder Marling Address 7
e.
City $fate tip
� ) 732- /374 Cf t w1llera MSh .0 »or
d.Facility name(discharge):
e. Facility address: I f-{ r1u.'«:s1
c15i)ty� �*79/
City State Zip
f. Facility contact person: --0a U;<1 ry uJ/e r�
rust / MI / Last
(4 ►�) 7 '2-2-374t city fit. Fowle✓©msn .com
Phone E-mail Address
Revised 7/2005

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information: (if different from the person legally responsible for the permit)
Permit contact.
First / MI/ Last
Title
Mailing Address
City State Zip
)
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior to
this ownership or name change?
Cr Yes
❑ No(please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,or a bill
of sale)is required for an ownership change request. Articles of incorporation are not sufficient for
an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and the new
applicant in the case of an ownership change request. For a name change request,the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION(Permit holder prior to ownership change):
j-=s f< ( ~c , 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 is not included, this
application package will be returned as incomplete.
Signature Date
APPLICANT CERTIFICATION:
I, -1.)li t lc , 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 is not included, this
application package will be returned as incomplete.
\-LA /
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
Revised 7/2005

1 Settlement Charges �. .
n �
,. r3 � �"A� ..fir •�
700'Total Sales/Broker's Commission: (based on price) 210,000.00 @ 6.00 % Paid from Paid From
Division of Commission (line 700) as follows: Borrower's Seller's
701. York, Simpson, Underwood $6300.00 Funds at Funds at
702. Oakland Ltd $6300.00 Settlement Settlement
703. Commission paid at Settlement 12,600.00
704.
800. Items Payable in Connection with Loan
801. Loan Origination Fee
802. Loan Discount
803. Appraisal Fee
804. Credit Report
805. Lender's Inspection Fee
806. Mortgage Insurance Application Fee
807.
808.
809.
810.
811.
812.
813.
814.
900. Items Required by Lender to Be Paid in Advance
901. Interest from to @$ per day 0.00
902. Mortgage Insurance Premium for
903. Hazard Insurance Premium for
904.
905.
1000. Reserves Deposited with Lender
1001. Hazard insurance months @ $ per month 0.00
1002. Mortgage insurance months @$ per month 0.00
1003. City property taxes months @ $ per month 0.00
1004. County property taxes months @ $ per month 0.00
1005. Annual assessments months @ $ per month 0.00
1006. months @ $ per month 0.00
1007.
1008.
1009. Aggregate Accounting Adjustment
1100. Title Charges
1101. Settlement/closing fee
1102. Abstract/title search
1103. Title examination
1104. Title insurance binder
1105. Document preparation James W.Tolin, Jr. 100.00
1106. Notary fees
1107. Attorney's fees To: James W. Tolin, Jr. 500.00
(includes above item numbers
1108. Title insurance To: Investors Title Insurance Company 225.20
(includes above item numbers
1109. Lender's coverage
1110. Owner's coverage
1111.
1112.
1113.
1200. Government Recording and Transfer Charges
1201. Recording Deed 17.00 Mortgage Release 17.00 0.00
1202. City/county tax/stamps: Deed Mortgage 0.00 420.00
1203. State tax/stamps: Deed Mortgage 0.00
1204.
1205.
1206.
1300. Additional Settlement Charges
1301. Survey
1302. Pest Inspection
1303.
1304.
1305.
1306.
1307.
1308, Express Delivery To: James W. Tolin, Jr. 60.00
1400. Total Settlement Charges (This Number Transfers to Lines 103 & 502 Above) 742.20 13,180.00
ti ;CERTIFICATION t ' `,,G t n 14 .. tlq 0 k,f n; ri
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of
all receipts and disbursements made on my account or by me in this transaction.^I further certify that I have received a copy of the HUD-1
Settlement Statemen, � �
t"*1-4- i C Seller � �; /ti �?z c_ Borrower
Jessie L. Moore, II and Rhonda T. Moore David W.Fowler
Seller
. Borrower
. .. ,ham
Jessie L. Moore, II and Rhonda T. Moore Janice W. Fowler
To the best f-my knowledge the HUD-1 Settlement Statement which I have prepared is true and accurate account of the funds which were
received nd hie been or will be disburs,44,by the undersigned as part of the s ment of this transaction.
7�, 1 Settlement Agent ��� 0��� Date
James W.Tblin, Jr. J
WARNING:It is a crime to knowingly make false statements to the United States on this or any other similar form.Penalties upon conviction can include a fine and imprisonment.For
details see:Title 18 U.S.Code Section 1001 and Section 1010.
Convrieht ThoroeFornu.com 2002

A. H4JD-1 UNIFORM SETTLEMENT STATEMENT
M
B. Typo. of Loan �
1.1] FHA 2.[] FmHA 3.[] Cony. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number:
4.[]VA 5.[] Cony. Ins.
C. NOTE: This form furnishes a statement of settlement costs.Amounts paid to and by the settlement agent are shown. Items marked
"(p.o.c.)"were paid outside the closing; they are shown for informational purposes and are not included in the totals.
D: Name &Address of Borrower: E. Name,Address&TIN of Seller: F. Name&Address of Lender:
David W.Fowler&Janice W. Fowler Jessie L. Moore, II and Rhonda T.Moore n.a.
G. Property Location: TIN of Seller: H. Settlement Agent:
581 Hideway Lane, Leasburg, NC Place of Settlement
James W.ToJin Jr.,
TM A4 Lot 137 112 South Main St.
Person County, NC Roxboro, North Carolina 27573 I. Settlement Date: Jun 13,2005
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 210,000.00 401. Contract sales price 210,000.00
102. Personal Property 402. Personal Property
103. Borrower's settlement charges (line 1400) 742.20 403.
104. 404.
105. 405.
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
106. Cit /town taxes to 0.00 406. Cit /town taxes to 0.00
107. Count taxes to 0.00 407. Count taxes to 0.00
108.Assessments to 0.00 408.Assessments to 0.00
109. to 0.00 409. to 0.00
110. 410.
111. 411.
112. 412.
113. 413.
120. Gross Amount Due from Borrower 210,742.20 420. Gross Amount Due to Seller 210,000.00
200. Amounts Paid by or in Behalf of Borrower: 500. Reductions in Amount Due to Seller:
201. Deposits or earnest money 3,000.00 501. Excess deposit(see instructions)
202. Principal amount of new loan(s� 502. Settlement charges to seller(line 1400) 13,180.00
203. Existing loan(s)taken subject to 503. Existing loan(s)taken subject to
204. 504. Payoff of first mortgage
205. 505. Payoff of second mortgage
506. Payoff American Naional Bank&Trust Co.
206. Funds from ITEC 160,098.64 Note number 1406248802 24,031.63
207. 507. Payoff CITI Mortgage 3683644 107,467.53
208. 508.
209. 509. Prorated Taxes TM A4 137 388.17
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
210. Cit /town taxes to 0.00 510. Cit /town taxes to 0.00
211. Count taxes to 0.00 511. Count taxes to 0.00
212.Assessments to 0.00 512.Assessments to 0.00
213. to 0.00 513. to 0.00
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. Total Paid By/for Borrower 163,098.64 520. Total Reduction Amount Due Seller 145,067.33
300. Cash at Settlement From/to Borrower 600. Cash at Settlement To/from Seller
301. Gross amount due from borrower line 120) 210,742.20 601. Gross amount due to seller line 420 210,000.00
302. Less amounts paid by/for borrower(line 220 163,098.64 602. Less reductions in amount due seller(line 520 145,067.33
303. Cash ® from ❑ to Borrower 47,643.56 603. Cash ® to ❑ from Seller 64,932.67
Substitute Form 1099 Seller Statement `; ''
Investors Title Exchange Corporation, as purchaser of this property pursuant to a replacement property assignment with David W. Fowler and
Janice W. Fowler and Seller, directed the Seller to convey title directly to David W. Fowler and Janice W. Fowler shown here as borrower for
convenience of reference only.
The information in Blocks E,G, H, I &line 401 (or,if line 401 is asterisked, line 403 and 404)is important tax information and is being furnished
to the Internal Revenue Service. If you are required to file a return, a sanction will be imposed on you if this item is required to be reported and
the IRS determines that it has not been reported. If this real estate is your principal residence,file Form 2119, Sale or Exchange of Principal
Residence, for any gain, with your income tax return; for other transactions, complete the applicable parts of Form 4797, Form 6252 and/or
Schedule D (Form 1040).You are required to provide the Settlement Agent(named above)with your correct taxpayer identification number. If
you do not provide the Settlement Agent with your taxpayer identification number,you may be subject to civil or criminal penalties imposed by
law. Under penalties of perjury, I certify that the number shown on this statement is my correct taxpayer identification number.
2,6/4. r /t"�°'Tt= (Seller) �'..-/` " sA'" (Seller)
Jessie L. Moore, II and Rhonda T. Moore Jessie L. Moore, II and Rhonda T. Moore
Convrieht ThnmeFnmic inn,9nm
A