NCG550291_Owner (Name Change)_20090904

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AgriIlrA,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director Secretary
September 4,2009
TODD R CONRAD AND
KIMBERLY G CONRAD
221 GREENLAWN DRIVE
KERNERSVILLE NC 27284
Subject NPDES Permit Modification-Name and/or Ownership
Change 221 Greenlawn Drive-Todd Conrad and Kimberly
Conrad—Residence
Formerly—Gerald Sapp—Residence
Certificate of Coverage NCG550291
Forsyth County
Dear Mr. and Mrs. Conrad: •
Division personnel have reviewed and approved your request for ownership change of the subject certificate of
coverage received on August 24,2009. This permit modification documents the change of ownership of the above
reference facility.
Please find enclosed the revised certificate of coverage. All other terms and conditions contained in the original
certificate remain unchanged and in full effect This modification 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 concerning this permit modification,please contact the Point Source Branch at(919)
807-6304.
Sincerely,
.61
441 gLi4"(
r.,4Coleen H. Sullins
cc: Central Files
Winston-Salem Regional Office,Surface Water Protection
NPDE&UnitEilez,
1617 Mail Service Center,Raleigh,North Carolina 27699-1617
Location:512 N.Salisbury St.Raleigh,North Carolina 27604 One
Phone:[phone] FAX:[phone] Customer Service:1-877-623-6748 NorthCaroliifna
cw Internet www.naterquality.org Natura/LN

STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
•
GENERAL PERMIT NCG550000
CERTIFICATE OF COVERAGE NCG550291
DISCHARGE OF DOMESTIC WASTEWATER FROM SINGLE FAMILY RESIDENCES AND
OTHER 100%DOMESTIC 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,
Todd R. Conrad and Kimberly G. Conrad
is hereby authorized to discharge domestic wastewater [450 GPD] from a facility located at
221 Greenlawn Drive
Kernersville
Forsyth County
to receiving waters designated as an unnamed tributary to Smith Creek in subbasin 03-07-04 of
the Yadkin River Basin in accordance with the effluent limitations;monitoring requirements, and
other conditions set forth in Parts I, II, III and W hereof. -
This certificate of coverage shall become effective September 4, 2009.
This Certificate of Coverage shall expire on July 31, 2012.
Signed this day September 4, 2009.
fo en H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

'1'•A1'4 •, Michael F.Easley,Governor
William G.Ross Jr.,Secretary
AUG20 2�1Dn9 North Carolina Department of Environment and Natural Resources
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1-5
Re
gi
Alan W.Klimek,P.E.Director
yv gi moo,--•, Division of Water Quality
onal Office
«3=> SU1�FA•CE;=WATER_PROTE•CThOM :SECTION��`::�:�r_''===`h�:=�`-,.,•.=�'�=
a - .s-, . VIE/O.WNERSHIP CHANGE'FORM: =:z'
. ..w� •-,. ,. ,, %;vir. ,.,.`.•r . r.. _..N e ,... ..-._ c•, •1 .. z ..._r«_. , ,.r .,. ,. _r..�.-.< ���',, ...`i'.t�"., -- ;,�.---,�c+�;,r;,..
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
:;N'-'•:C-0 5 5 Z. 9 1
•
•
II. Permit status prior to status change.
a. Permit issued to(company name):
b. Person legally responsible for permit: G EQ,4LI) V1 5A-QP
First / MI / Last
Title
2-?1 G4, l t,I1-w
Permit Holder Mailing Address •
Vre ea—S v i uLa NC__ 2 7 2Sy
City State Zip
( ) ( )
Phone Fax
c. Facility name(discharge):
d. Facility address:
Address
City State Zip
e. Facility contact person: ( )
• First / MI / Last Phone
III. Please provide the following for the requested change(revised permit).
•
a. Request for change is a result of: ' Change in ownership of the facility
❑ Name change of the facility or owner
If other please explain:
b. Permit issued to(company name):
c. Person legally responsible for permit:- ��'� Q E ivE D • C'c jA)
First / MI / Last
1 ETitle
C;? i C— R j LAW AJ 7 Q .
Permit Holder Mailing Address
• AUG 2 4 2009 K E12Nt~RS J fit= Al C "Ia*/
City State Zip
(33ta) o r7 ate
DEN R - � T ���4 ) Phone E-mail Address
a I r e :
POINT SO4.a&i RANCH Address
City State Zip
f. Facility contact person:
First / MI / Last
( )
Phone E-mail Address
Revised 7/2005

PERMIT NAME/OWNERSHIP CHANGE FORM
Page2of2
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 co'ntinue to conduct the same industrial activities conducted prior to
this ownership or name change?
[ 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 hol er prior to ownership change):
I, �� /.S� Y , attest that this application for a name/ownership
_ change has been reviewed and is(ccur to 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 t
APPL CANT CERTIFICAT>;�
1� AeSi2.uG�.� , attest that this application for a name/ownership
change has been reviewe nd 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.
/2ee46c11/1 /
ature 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

OWNERS FORM `;
Order #
CHICAGO TITLE INSURANCE COMPANY
P. O. Box 20365 • Winston-Salem, NC 27120
Phone: [phone] • Fax: [phone]
SCHEDULE A
OFFICE FILE NUMBER POLICY NUMBER DATE OF POLICY AMOUNT OF INSURANCE
WS07-0017222 34 106 WS07-0017222 June 15, 2007 $242,000.00
at 4:45 P.M.
1. Name of Insured:
TODD R. CONRAD AND WIFE KIMBERLY G. CONRAD
2. The estate or interest in the land which is covered by this policy is:
Fee Simple
3. Title to the estate or interest in the land is vested in the insured.
4. The land herein described is encumbered by the following mortgage or trust deed, and assignments:
Deed of Trust from KIMBERLY GRACIA CONRAD AND TODDY RAY CONRAD, WIFE AND HUSBAND
to MICHAEL J. BROKER, Trustee for USAA FEDERAL SAVINGS BANK, dated June 15,
2007, filed for record June 15, 2007, at 4:45 P.M. , in Book 2761, page 2533,
Forsyth County Registry, securing $242,000.00.
and the mortgages or trust deeds, if any, shown in Schedule B hereof.
5. The land referred to in this Policy is described as follows:
Lying and being situate in Forsyth County, North Carolina, and more particularly
described as follows:
See attached Exhibit "A"
SCHEDULE A
Owners Form This Policy valid only if Schedule B is attached

EXHIBIT A
Todd R. Conrad and wife, Kimberly G. Conrad a
0.64 acres along Greenlawn Drive
221 Greenlawn Drive
Commencing at an iron marking the corner of Ben Idol and Roger L. Hastings, Jr. in the line of
Thomas G. Smith; thence from said commencing point with the line of Smith and Hastings,
South 07° 48' West 303.14 feet to an iron marking a corner of Roger L. Hastings, Jr. and said
iron also marks the northwest corner of this property and the point and place of BEGINNING;
thence from said-beginning point along Smith's line, South 07° 48' West 140.00 feet to an iron
marking the southwest corner of this property and the northwest corner of J. Wayne Davis;
thence with the Davis line, South 82° 12' East 200.00 feet to an iron along the western margin of
Greenlawn Drive, said iron also marking the southeast corner of this property; thence along the
western margin of Greenlawn Drive, North 07° 48' East 140.00 feet to an iron in the line of
Roger L. Hastings, Jr. and also marking the northeast corner of this property; thence with
Hastings' line, North 82° 12' West 200.00 feet to an iron marking the point and place of
BEGINNING. (This property contains approximately 0.64 acres according to the Forsyth
County tax maps.)
The above described,property is the same as that property described in Book 1264, Page 1068
and is designated as Tax Lot 102R in Block 5646, on the Forsyth County tax maps.
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