SW3150202_Permit Information Update Form_20240117

DEMLR USE ONLY
Date Received Fee Paid Permit Number
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STATE STORMWATER:
PERMIT INFORMATION UPDATE APPLICATION FORM
There is NO FEE for updating project name or permittee information.
This form is to only to be used by the current permittee to notify the Division of:
1) changes to the Point of Contact(signing official) for the current permittee (LLC, Corporation, HOA or PGA);
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project;and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
A. NEW PERMIT INFORMATION
State Stormwater Permit Number: SW 3150202
Are you updating If so, please provide the updated information:
(check all that apply):
❑ Project name
❑ Corporation Name1
® Permit Contact Name2,3 Joe Young
❑ Permit Contact Title
® Mailing Address3 2013 Rocky Hollow Drive, Marvin, NC 28173
® Phone number 980-307-1998
® Email address Joeyoung1968Ca�icloud.com
Provide documentation such as a Name Change/Merger filed with the NCSOS.
2 Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A NCAC 02H .1040(1).
3 If more than one point of contact or mailing address is being changed, please attach a separate sheet.
B. CERTIFICATION OF PERMITTEE
I, Joe Young ,the current permittee, hereby notify DEMLR that I am making the changes as
listed in Section A above. I further attest that this application for an update to the permit information currently on file is
accurate and complet to the best of my knowledge. /
Signature: y�t. �` Date: 'li. /, '
I, Mi 7--( , a Notary Public for the State of I\�s C'�rr�►, �
County of )Y c,Liky,,L , do hereby certify that qe Jr:),5'e,414 Y©j
personally appeared before me this the ) ( day of S ` er , 20 , and acknowledge the due
execution of the forgoing instrument. Witness my hand and official seal,
ysoiEpF.re,.
(Notary Seal)
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Notary Signature 4, 11*r-
••; r ;
My Commission Expires _ f
My commission expires April 11,2026
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Stormwater Permit Information Update Form Page 1 of 1 `" ""' May 11, 2017