WQ0001989_Additional Information Response_20210223

SYNAGRO
YOUR PARTNER FORA GLEANER, GREENER WORLD
February 16a', 2021
N.C. Department of Environment and Natural Resources
Division of Water Resources
Water Quality Permitting Section — Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
ATTENTION: Ms. Lauren Plummer
REFERENCE: Follow up to Additional Information Request WQ0001989
Roanoke Rapids Sanitary District RLAP
Halifax County
G. Land Application Site Certification(s)
1. Land Owner Agreements (LOA) for the following fields do not appear to match the deed information
available per County GIS maps. Please note that reciprocating setback waivers are necessary for
adjacent parcels not owned by the same individual but are being submitted as a single field.
Please review the following discrepancies, provide the additional documentation as necessary, and
revise the LASC and LOA forms as needed to reflect these changes:
a. For Field NC-HX-06-01, located on Parcel No. 0701623, county GIS lists the owners as Matt
Ransom Johnston and William Ransom Johnston. The provided LOA was signed by Bernard
F. Morris, Jr., please provide an LOA for Mr. Johnston.
Corrective action: Field NC-FIX-06-01 was omitted. Acreage and maps were adjusted. (See
LASC)
b. Field NC-HX-06-02 is located across three parcels, Parcels No. 0702029 and 0702026 are
owned by Bernard F. Morris, Jr. However, the county GIS lists the owner of Parcel No.
0704912 as Bernard Michael Morris. The provided LOA was signed by Bernard F. Morris, Jr.,
please provide an LOA for Bernard Michael Morris, the necessary reciprocating setback
waivers, and an updated site map depicting the setback.
Corrective action: Bernard Michael Morris ' LOA was obtained. Acreage and maps were
adjusted. (See attached documentation)
c. Field NC-HX-06-03 is located across three parcels, Parcels No. 0706158 and 0702038 are
owned by Bernard F. Morris, Jr. However, the county GIS lists the owner of Parcel No. 0702030
as Bernard Michael Morris and Debbie P Morris. The provided LOA was signed by Bernard F.
Morris, Jr., please provide an LOA for the parcel not owned by Bernard F. Morris, Jr., the
necessary reciprocating setback waivers, and an updated site map depicting the setback.
Corrective action: Bernard Michael Morris' LOA was obtained. Acreage and maps were
adjusted. (See attached documentation)

SYNAGRO
YOUR PARTNER FOR A GLEANER, GREEN ER WORLD
d. Field NC-HX-07-01 is located across two parcels. The county GIS lists Philip Edward West
as the owner of Parcel 0200380 and Fred G. West as the owner of Parcel 0200378. The provided
LOA was signed by Ms. Rosamund West, please provide LOAs for these parcels that are signed
by the owner. Additionally, please provide the necessary reciprocating setback waivers and an
updated site map depicting the setback at the property boundary.
Corrective action: Parcel 0200380 was omitted (Phillip Edward West). I spoke with Ms.
Rosamond West and she is the executrix for Fred G. West estate as Fred G. West is deceased.
Acreage and maps were adjusted. (See attached documentation)
e. Field NC-NO-10-01 is located across two parcels, Parcels No. 4041-20-1775 and 4041-30-2993.
The county GIS lists John L. Carpenter, Jr. as the owner for these parcels; however, the provided
LOA was signed by Stephen Lucas Clements. Please provide an LOA for Mr. Carpenter.
Corrective action: Field NC-NO-10-01 was omitted. Acreage was adjusted. (See LASC)
f. For Field NC-NO-12-1, located on Parcel No. 4949-97-2062, county GIS lists the owners as
Laura J. Ferguson and Kathryn J. Hamilton. The provided LOA was signed by Howard Ferguson,
please provide an LOA signed by an owner of the property.
Corrective action: Laura Ferguson's LOA was obtained (see attached documentation)
g. For Fields NC-NO-21-(68-72), the associated parcels are owned by Hugh K Aiken, Jr. Trustee.
Please provide additional information that Ms. Clairene H. Aiken has the authority to sign the
LOA for these parcels.
Corrective action: I spoke with Ms. Clairene H. Aiken and she is the executrix of the Hugh K
Aiken. Jr. Trust as Hugh K. Aiken Jr. is deceased.
2. According to the submitted maps, there appear to be multiple water supply wells that would be
located within the compliance boundaries of land application fields. 15A NCA 02L .0107(d) prohibits
the construction or operation of water supply wells within the compliance boundary, which is
established either 250 feet from the waste boundary or 50 feet within the property boundary,
whichever is closer to the source [15A NCAC 02L .0107(b)]. Water supply wells appear to be within
the compliance boundaries for the following fields:
• NC-HX-06-03 — One well is located on Mr. Bernard Michael Morris's property south of
Wright Road and west of the field, and one well is located on Mr. Bernard F. Morris Jr.'s
property south of Wright Road and east of the field.
• NC-NO-10-(02-03) — The well located between Fields 02 and 03.
• NC-WR-03-02 — The well to the south of the field.
• NC-NO-12-01
— The well at the center of the field.
• NC-NO-21-06 — The well to the northwest of the field.
• NC-NO-21-33
— The well to the northeast of the field.
• NC-NO-21-22
— The well to the north of the field.
• NC-NO-21-27
— The well to the north of the field.

SYNAGRO
YOUR PARTNER FOR A GLEANER, GREENER WORLD
An alternative to this requirement can be approved in accordance with 15A NCAC 02T .0105(h).
Upon the Permittee's request, the compliance boundary may be located closer to the waste disposal area
(i.e. more restrictive) due to an on -site water supply well. If this option is chosen, the following items
shall be resubmitted:
a. Section III on page 2 of 3 of the Land Owner's Agreement form (LOA 06-16) shall be updated
for the above fields to request for the alternative boundary; and
Corrective action: See updated LOA forms (page 2 of 3) for affected fields.
b. A letter requesting redefined boundaries for all affected fields. For example, a statement that
says "Field NC-XX-XX-XX: A redefined compliance boundary is requested for this site. The
redefined compliance boundary is located [LOCATION] and shall be located 50 feet from the
well located on [LANDOWNER'S NAME] property" would be acceptable for each request.
New maps do not need to be submitted, just a letter requesting redefined boundaries for all
affected fields. Please note that the new boundary must be at least 50 feet from the water supply
well.
Corrective action: See attached redefined compliance boundary letter.
3. Our records indicate that parcel NC-HX-09-07 owned by Nat Justice West (Parcel 0703013) is
already active and associated with Permit No. WQ0001989. This field was previously included as
a residual site for WQ0001989 under the September 5, 2007 permit. Cumulative Pollutant Loading
Rate (CPLR) results are necessary for fields that have previously been active residual sites.
Corrective action: See attached CPLR results for NC-HX-09-07.
H. Site Maps:
1. The site map for NC-WR-3-2 indicates rock outcrops throughout the application area. Rock outcrops
are not suitable for land application, and setbacks — which were not depicted — are required pursuant
to 15A NCAC 02T .I 108(c). These setbacks will modify the acreage of field NC-WR-3-2. Please
update the site map and the LASC documents as necessary.
Corrective action: Rock outcrop setbacks are now depicted. See updated site map and LASC.
Best regards,
Chris Wynne
Technical Services Specialist

SYNAGRO
YOUR PARTNER FOR A CLEANER, GREENER WORLD
February 8 h, 2021
N.C. Department of Environment and Natural Resources
Division of Water Resources
Water Quality Permitting Section — Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
ATTENTION: Ms. Lauren Plummer
REFERENCE: Follow up to Additional Information Request WQ0001989
Roanoke Rapids Sanitary District RLAP
Halifax County
Ms. Plummer,
I am addressing the redefined compliance boundaries due to on -site water supply wells for the
affected fields. See below.
(NC-HX-06-03) - The redefined compliance boundary is located east of Bernard Michael
Morris's property south of Wright Road and west of the field. For the other well, the redefined
compliance boundary is west of the well located on Mr. Bernard F. Morris Jr.'s property south of
Wright Road and east of the field and shall be located 50 feet from the well located on Bernard
F. Morris Jr.'s and Bernard Michael Morris' property.
(NC-NO-10-02, 03) - The redefined compliance boundary is located north of the well located
between Fields 02 and 03 and shall be located 50 feet from the well located on Stephen Lucas
Clements' property.
(NC-WR-03-02) - The redefined compliance boundary is located northeast of the well located at
the south of the field and shall be located 50 feet from the well located on Scott West's property.
(NC-NO-12-1) - The redefined compliance boundary is located outside of the well located at the
center of the field and shall be located 50 feet from the well located on Laura Ferguson's
property.
(NC-NO-21-06) - The redefined compliance boundary is located southeast of the well and shall
be located 50 feet from the well located on Mary Howell's property.
(NC-NO-21-33) - The redefined compliance boundary is located southwest of the well and shall
be located 50 feet from the well located on Rod Howell's property.
(NC-NO-21-22, 27) - The redefined compliance boundary is located south of the well and shall
be located 50 feet from the well located on Jim Deal's property.

SYNAGRO
YOUR PARTNER FOR A GLEANER, GREENER WORLD
Please find that all Land Owner's Agreement forms are updated to reflect the redefined
compliance boundaries and field adjustments. Please let me know if any further information is
needed regarding the redefined compliance boundaries for on -site water supply wells for affected
fields.
Best regards,
Chris Wynne
Technical Services Specialist

State of North Carolina
Department of Environmental Quality
Division of Water Resources
LAND APPLICATION SITE CERTIFICATION
INSTRUCTIONS FOR FORM: LASC 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supportine documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General — This certification provides detailed information of receiving sites for land application of Class B residuals (may include
water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit this certification for review
without a corresponding application form (FORM: RLAP 06-16 or FORM: SDR 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Application Site Certification (FORM: LASC 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® For new or renewed permits, submit the requested information for all land application sites.
® For modified permits, submit the requested information for only those sites that are new, transferred or affected by the
proposed modification.
B. Land Application Site Information:
® The status of the land application site with respect to this residuals land application program must be provided in table I. The
status categories and their corresponding codes are as follows:
♦ New (N) ♦ Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
® Attach the following in accordance with each status code:
Status Code
Required Item
N
R
T
M
County Board
Notification. doc
Land Owner
Agreement
(If applicable)
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Map Guidance
for Residuals Land Application Pennits"
✓
✓
✓
A soils and agronomic evaluation in accordance with the "Soil Scientist
Evaluation Policf'
INSTRUCTIONS FOR FORM: LASC 06-16 Paget of 3

An updated accounting of the land application site's cumulative
pollutant loading rates (CPLRs)
Status Code
Required Item
N
R
T
M
For previously permitted sites without a soil series name indicated in the
Attachment B, submit County Soil Survey Map (or equivalent) clearly
indicate the location of the land application site and in accordance with
the soil map requirements in the "Soil Scientist Evaluation Policv"
Acknowledgement of field transfer from Land Owner (Fields may not
✓
be permitted to multiple Permittees over the same timeperiod)
* This item may be required for land application site with a status code "M", please contact the Division if you need assistant in
determining attachment requirements.
® Crop Type should include the most likely crop types for the life of the permit (five years).
® Predominant Soils Series Name must be either the name of the soil indicated in Attachment "B" of the existing permit, or
name of the soil series as provided by the licensed soil scientist.
® Predominant Soil Mapping Unit or Representative Slope: Either the Soil Mapping Unit or the representative slope of each
site must be provided. The predominant soil -mapping unit must be consistent with the predominant soil series name. Please
note that the soil mapping units are variable between Counties, so care should be taken in properly identifying the correct
mapping unit. If a representative slope is provided, it must be determined accordingly:
® For sites previously permitted for use, but do not have an established soil mapping unit (the mapping unit provides
information on both the soil series name and the slope of the soil), the Applicant may determine the representative slope
by using the average slope provided in the County Soil Survey (or equivalent). A soil type with a slope range of 4 - 8%
would have a representative slope of 6%.
® New Sites to be permitted must have slopes determined as part of the soils report prepared by a licensed soil scientist.
® Acceptable methods for determining location coordinates (i.e., latitude and longitude) and their corresponding codes are as
follows:
• Address Matching (ADD) • Digital or Raw Photo Extraction (EXT)
• Aerial Photography with Ground Control (AER) • Geodetic Quality GPS Survey (GEO)
• Cadastral Survey (SUR) • LORAN-C Navigation Device (LOR)
• Conversion from Coordinate Plane (CP) • Navigation Quality GPS (GPS)
• Conversion from Township -Section -Range (TSR) • Remote Sensing (RS)
• Conversion from Universal Trans Merc (UTM) • Zip Code Centroid (ZIP)
• Map Interpretation by Digital or Manual Extraction (MAP)
C. Waterbody and Classifications Information: (new sites only)
® Use an 8.5 by 11-inch copy of the portion of a 7.5-minute USGS Topographic Map to identify the location where the
residuals program activities are planned to occur as well as the closest downslope surface waters as clearly as possible. Each
map portion must be labeled with the map name and number, the identified location, and be of clear and reproducible quality.
® Surface water body classifications information may be found at: hgp://deq.nc.pov/about/divisions/water-
resources/plannin /g classification-standards/classifications
® Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
® A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
http:Hdeg.nc.jzov/contact/re ion nal-offices
® General Instructions: There are 17 river basins in North Carolina. Each basin has associated waterbodies with assigned
subbasins, location descriptions, stream index numbers and established classifications.
1. Identify the project area on a 7.5 minute USGS topographical map (an 8.5 x 11-inch sheet showing the project area
should be submitted with the permit application regardless of whether a Stream classification was completed).
2. Determine the names of all the closest down slope surface waters from the project site. For unnamed tributaries, see
Table 1: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream name" as the waterbody name.
3. Open the link htt�://decl.nc. ov/about/divisions/water-resources/planning/classification-standards/classifications.
® Stream Classification Process: One of the options below may be used depending on the known initial project information.
® KNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select proper basin from the List all Waterbodies in Basin sorted report. Sort hydrologically as this will provide
the proper location descriptions if multiple runs.
INSTRUCTIONS FOR FORM: LASC 06-16 Page 2 of 3

2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
® KNOWN COUNTY WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select the proper county from the List all Waterbodies in county, hydrologically report.
2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
® UNKNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Use the Clickable basin map to hydrologically sorted list report.
2. Click on the approximate project location to bring up the hydrologically sorted list.
3. Locate the name of the identified waterbody (from General Directions) on the list.
4. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
5. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
® Notes on index number and unnamed streams:
Unnamed Streams 15A NCAC 02B .0301(i).
® Any stream which is not named in the schedule of stream classifications carries the same classification as that assigned
to the stream segment to which it is tributary (at the point of entry) except:
(A) unnamed streams specifically described in the schedule of classifications;
(B) unnamed freshwaters tributary to tidal saltwaters will be classified "C"; or
(C) after November 1, 1986, any newly created areas of tidal saltwater which are connected to Class SA waters by
approved dredging projects will be classified "SC" unless case -by -case reclassification proceedings are conducted.
® The following river basins have different policies for unnamed streams entering other states or for specific areas of the
basin:
Unnamed Tributaries Entering Other States or for Specific Basin Areas
Hiwassee River Basin
Streams entering Georgia or Tennessee shall be classified "C Tr."
Little Tennesse River
Basin And Savannah
River Drainage Area
Streams entering Georgia or Tennessee shall be classified "C Tr." Such streams in the Savannah
River drainage area entering South Carolina shall be classified "B Tr."
French Broad River
Basin
Streams entering Tennessee will be classified "B."
Watauga River Basin
Streams entering the State of Tennessee are classified "C."
Broad River Basin
Streams entering South Carolina are classified "C."
New River Basin
Streams entering the State of Tennessee are classified "C."
Catawba River Basin
Streams entering South Carolina are classified "C."
Yadkin -Pee Dee River
Basin
Streams entering Virginia are classified "C," and such streams entering South Carolina are
classified "C."
Lumber River Basin
Streams en_t_ering South Carolina are classified "C Sw."
Roanoke River Basin
Streams entering Virginia are classified "C." Except that all backwaters of John H. Kerr
Reservoir and the North Carolina portion of streams tributary thereto not otherwise named or
described shall carry the classification "B," and all backwaters of Lake Gaston and the North
Carolina portion of streams tributary thereto not otherwise named or described shall carry the
classification "C and B."
Chowan River Basin
Streams entering Virginia are classified "C."
Tar -Pamlico River
Basin
All drainage canals not noted in the schedule are classified "C Sw." except the main drainage
canals to Pamlico Sound and its bays which shall be classified "SC."
Pas uotank River Basin
All drainage canals not noted in the schedule are classified "C."
INSTRUCTIONS FOR FORM: LASC 06-16 Page 3 of 3

LAND APPLICATION SITE CERTIFICATION
Applicant's name: Roanoke Rapids Sanitary District
Land application sites currently certified: 1985.46 net acres and Total to be certified: 1487.73 net acres.
I. LAND APPLICATION SITE INFORMATION (See Instruction B):
Status
Codes
Site/Field ID
Landowner(s) s
Lessee(s) P Operator(s) or O s
Net Acres
CountyPt
Cro s)
Predominant Soil
Series Namee
Mapping Unit
or Rep. Slope°
N
NC-HX-6-2
I Bernard F. Morris Jr.
51.38
Halifax
Row Crop
Wedowee
2%
N
NC-HX-6-3
Bernard F. Morris Jr.
40.54
Halifax
Row Crop
Wedowee
1 2%
N
NC-NO-10-2
Stephen Lucas Clements
28,86
Northampton
Pasture
Caroline
2%
N
NC-NO-10-3
I Stephen Lucas Clements
17.54
Northampton
I Pasture
Bonneau
20%
N
NC-HX-9-7
Nat Justice West
58.6
Halifax
Pasture
Wedowee
2%
N
NC-11X-7-1
RosamondJ, West
7.11
Halifax
I Pasture
Wedowee
2%
N
NC-WR-3-2
I William Scott West
I 42.53
Warren
Pasture
Pacolet
2%
R
NC-N0-5-1A
FRoanoke Rapids Sanitary District
Howard Ferguson
43.22
Northampton
Pasture
Norfolk
0-10%
R
NC-NO-5-113
Roanoke Rapids Sanitary District
Howard Ferguson
35.29
Northampton
Pasture
Norfolk
I 0-10%
R
NC-NO-9-1
Bobby Lee
I
16.02
Northampton
Pasture
Caroline
I 2%
R
NC-NO-9-2
Bobby Lee
40.49
Northampton
Pasture
Caroline
4%
R
NC-NO-12-1
Laura Ferguson
56.93
Northampton
Pasture
Marlboro
( 0-10%
R
NC-NO-12-2
Laura Ferguson I
15.45
( Northampton
Pasture
Gritney
0-10%
R
NC-NO-21-1
Mary G. Howell
Rod Howell
45.01
Northampton
Row Crop
Bonneau
0-100/0
R
NC-NO-21-2
Mary G. Howell
Rod Howell
76.85 I
Northampton
Row Crop
Norfolk
0-10%
R
NC-NO-21-3
Mary G. Howell
Rod Howell
29.20 f
Northampton
Row Crop
Norfolk
0-10%
R I
NC-NO-21-4
Mary G. Howell
Rod Howell
8.44
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-5
Mary G. Howell
Rod Howell
12.11
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-6
Mary G. Howell
Rod Howell
20.95
Northampton
Row Crop I
Norfolk
0-10%
R
NC-NO-21-7
Mary G. Howell
Rod Howell
6.14
Northampton
Row Crop
Goldsboro
0-10%
R
NC-NO-21-8 (
Mason Howell Jr
Rod Howell
17.51
Northampton
Row Crop I
Ngrfaik
0-10%
R
NC-NO-21-9 I
WE u _ ,
Rod Howell
12.37
Northampton
Row Crop
Norfolk
0-10%
FORM: LASC 06-16 Page 1

LAND APPLICATION SITE CERTIFICATION
R
NC-NO-21-10
Sally Barnette
Rod Howell
24.40
Northampton
Row Crop
Norfolk
0-10%
R
I NC-NO-21-12
I Mason Howell Jr
( Rod Howell
42.60
I Northampton
I Row Crop
I Norfolk
0-10%
R
NC-NO-21-14
, Mason Howell
I Rod Howell
22.67
( Northampton
1 Row Crop
I Norfolk
0-10%
R
NC-NO-21-19
Mason Howell
Rod Howell
22.39
Northampton
Row Crop
Goldsboro
0-10%
R
NC-NO-21-20
I James Deal
Rod Howell
21.29
Northampton
Row Crop
I Gritney
0-10%
R
I NC-NO-21-21
James Deal
Rod Howell
9.28
Northampton
Row Crop
Gritney
0-10%
R
I NC-NO-21-22
I James Deal
Rod Howell
15.96
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-23
I James Deal
Rod Howell
10.88
Northampton
Row Crop
Norfolk
0-10%
R
NC-NO-21-24
James Deal
Rod Howell
2.85
Northampton
Row Crop
Norfolk
0-10%
R
NC-NO-21-25
James Deal
Rod Howell
4.83
f Northampton
Row Crop
1 Norfolk
0-10%
R
NC-NO-21-26
I James Deal
Rod Howell
2.43
I Northampton
Row Crop
Bonneau
0-10%
R
I NC-NO-21-27
I James Deal
Rod Howell
10.21
Northampton
I Row Crop
I Norfolk
0-10%
R
NC-NO-21-29A
Mason Howell III
Rod Howell
21.85
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-29B
Mason Howell III
Rod Howell
11.51
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-30
Mason Howell
Rod Howell
I 7.25
Northampton
I Row Crop
Norfolk
0-10%
R
NC-NO-21-31
Mason Howell
Rod Howell
I 3.56
Northampton
Row Crop
Norfolk
0-10%
R
NC-NO-21-33
Mason Howell,
Rod Howell
3.96
I Northampton
Row Crop
Caroline
0-10%
R
NC-NO-21-35
Mason Howell:
Rod HowellI
3,307
Northampton
Row Crop
Craven
0-10%
R
NC-NO-21-36
Mason Howell I
Rod Howell
30.99 I
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-38
Mason Howell I
Rod Howell
14.80 ,
Northampton
Row Crop
Gritney
0-10%
FRR
NC-NO-21-39
Mason Howell
Rod Howell
4.36
Northampton
Row Crop
Gritney
0-10%
NC-NO-21-40
Mason Howell
Rod Howell
2.48
Northampton
Row Crop
Gritney
0-10%
R {
NC-NO-21-41
Mason Howell
Rod Howell
2.31 I
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-42
Mason Howell I
Rod Howell
1.76 I
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-43
Mason Howell I
Rod Howell
18.66 I
Northampton
Row Crop
Goldsboro
0-10%
R
NC-NO-21-44
Mason Howell
Rod Howell
39.56 ,
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-52
Mason Howell
Rod Howell
31.13 I
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-53
Sarah Martin
Rod Howell
18.14
Northampton
Row Crop
Gritney
0-10%
FORM: LASC 06-16 Page 2

LAND APPLICATION SITE CERTIFICATION
R
NC-NO-21-54
Sarah Martin
Rod Howell
3.03
Northampton
Row Crop
Goldsboro
0-10%
R
NC-NO-21-55
Sarah Martin
Rod Howell
0.9
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-56
Sarah Martin
Rod Howell
8.52
Northampton
Row Crop
Gritney
0-10%
R
NC-NO-21-57
Mason Howell
Rod Howell
69.38
Northampton
Row Crop
Gritney
4%
R
NC-NO-21-58
Mason Howell III
Rod Howell
23.45
Northampton
Row Crop
Gritney
3%
R
NC-NO-21-59
David and Gary Bass
Rod Howell
9.49
Northampton
Row Crop
Norfolk
3%
R
NC-NO-21-60
David and Gary Bass
Rod Howell
16.28
Northampton
Row Crop
Gritney
4%
R
NC-NO-21-61
David and Gary Bass
Rod Howell
9.83
Northampton
Row Crop
Bonneau
4%
R
NC-NO-21-62
Mason Howell III
Rod Howell
10.24
Northampton
Row Crop
I Gritney
4%
R
NC-NO-21-63
Bruce Howell
Rod Howell
21.56
Northampton
Row Crop
Gritney
4%
R
NC-NO-21-64
Bruce Howell
Rod Howell
20.89
Northampton
I Row Crop
I Gritney
3%
PR-
NC-NO-21-65
Bruce Howell
Rod Howell
21.21
Northampton
Row Crop
Gritney
3%
R
NC-NO-21-66
Bruce Howell
Rod Howell
15.83
Northampton
Row Crop
Gritney
3%
R
NC-NO-21-67
Sarah Martin
Rod Howell
31.25
I Northampton
I Row Crop I
Gritney
I 3%
R
NC-NO-21-68
Hugh Aiken
Rod Howell
47.13
Northampton
Row Crop
I Gritney
I 3%
R
NC-NO-21-69
Hugh Aiken
Rod Howell
19.15
Northampton
I Row Crop
Norfolk
3%
R
NC-NO-21-70
Hugh Aiken
Rod Howell
31.82
Northampton
Row Crop
I Gritney
3%
R
NC-NO-21-71
Hugh Aiken
Rod Howell
14.08
Northampton
Row Crop
I Gritney
3%
R
NC-NO-21-72
Hugh Aiken
Rod Howell
35.26
Northampton I
Row Crop
Gritney
I 3%
D
NC-ED-1-1
Gail Batchelor
43.77
Edgecombe
Pasture
Altavista
3%
D
NC-ED-1-2
Mount Crossfield Farms I
41.05
Edgecombe I
Pasture
Norfolk
3%
D
NC-ED-1-3
Mount Crossfield Farms
40.54
Edgecombe
Pasture
Goldsboro
3%
D
NC-HX-2-1
Ray Batchelor
19.15
Halifax
Pasture
Goldsboro
4%
D
FD
NC-HX-2-2
Ray Batchelor (
21.77
Halifax
Pasture
Gritney
4%
NC-HX-2-1
Ray Batchelor
108.18
Halifax
Pasture
Gritney
6%
D
NC-HX-2-4
Ray Batchelor
38.13
Halifax
Pasture
Gritney
4%
D
NC-HX-2-5
Ray Batchelor
94.95
Halifax
Pas ure
Gritney
4%
D
NC-HX-2-6
Ray Batchelor
13.83
Halifax
Pasture
Emporia
5%
FORM: LASC 06-16 Page 3

LAND APPLICATION SITE CERTIFICATION
I
NC-HX-2-7
Ray Batchelor
11.78
Halifax
Pasture
Gritney
3%
D
NC-HX-2-8
I Ray Batchelor
50.67
Halifax
Pasture
Gritney
4%
D
NC-HX-2-9
Ray Batchelor
40.28
Halifax
Pasture
Gritney
6%
D
NC-HX-2-10I
Carlos Burt
37.55
t"
, ,, "'
Emporia
4%
D
NC-HX-13-12
Edwin Gregory
36.98
Halifax
Pasture
Bonneau
4%
D
NC-HX-13-13
( Edwin Gregory
23.52
Halifax
Pasture
Bonneau
4%
D
NC-HX-13-14
I Edwin Gregory
89.29
Halifax
Pasture
Emporia
4%
D
NC-NO-1-1
Charles King
11.21
Northampton
Pasture
Bonneau
3%
D
NC-NO-1-3 I
Charles King
I
18.31
Northampton
Pasture
Bonneau
6%
a Status Code for land application sites are: ♦ N (New) ♦ R (Renewed) ♦ M (Modified) ♦ T (Transferred) ♦ D (Deleted)
b Soil Series Name (i.e. Appling, Cecil, etc.)
Mapping Unit must be consistent with those used in the County Soil Survey (i.e. for a 2-8% slope Cecil in Anson County the mapping unit is CeB2)
II. WATERBODY AND CLASSIFICATIONS INFORMATION (See Instruction C):
Site/Field ID
Latitude
Longitude
g
Location
Datum
Location Method Code
Location Accuracy
Waterbody Subbasin and
Stream Index No.
Current and Proposed
Class
NC-HX-6-2
36024'29.98
77051'2.37
NAD 83
ADD
Nearest Second
Bear Swamp, 28-79-25-7
C;NSW
NC-HX-6-3
36023'58.74
77050'13.79
NAD 83
ADD
Nearest Second
Bear Swamp, 28-79-25-7
C;NSW
NC-NO-10-2
36032'24.08
77028'3,79
NAD 83
ADD
d Secon
NearestCypress
Creek, 25-4-3
C;NSW
NC-NO-10-3
36°32'25.61
77°2751.76
NAD 83
ADD
Nearest Second
Cypress Creek, 254-3
C;NSW
NC-HX-9-7
36022'57.37
77°54'l3.89
NAD 83
ADD
I Nearest Second
Butterwood Creek, 28-79-25-7-1
C;NSW
{
NC-7-136022'47.97
77°54'7.60
NAD 83
ADD
Nearest Second I
Butterwood Creek, 28-79-25-7-1
C;NSW
NC-WR-3-2
36023'1.73
177054'35.55
NAD 83
ADD
I Nearest Second
Bens Creek, 28-79-25-4
C;NSW
NC-N0-5-lA
36032'36.13
177042'19.39
NAD 83
ADD
I Nearest Second
NC-NO-5-113
I 36032'36.59
77042'30.34
NAD 83 I
ADD
Nearest Second
NC-NO-9-1
36032'37.15
77040'16.86
NAD 83
ADD I
Nearest Second
Beaverpond Creek, 25-4-2-2
C;NSW
NC-NO-9-2
36032'27.99
77040'21,56
NAD 83
ADD
Nearest Second I
Beaverpond Creek,25-4-2-2
C;NSW
NC-NO-12-1 I
36028'48.93
7702822.29
NAD 83
ADD l
Nearest Second
NC-NO-12-2
36°2855.56
7702827.42
NAD 83
ADD
Nearest Second
NC-NO-21-1
36°30'33.25
77018'29.88
NAD 83
ADD
Nearest Second
FORM: LASC 06-16 Page 4

LAND APPLICATION SITE CERTIFICATION
NC-NO-21-2
36°3034.52
77°18'41.70
NAD 83
ADD
Nearest Second
1 NC-NO-21-3
I 36°3051.69
77° 18'27.31
' NAD 83
I ADD
Nearest Second
NC-NO-21-4
I 36-31'0.49
77°18'19.62
NAD 83
I ADD
Nearest Second
NC-NO-21-5
36-31'3.81
177°18'27.30
NAD 83
I ADD
Nearest Second
NC-NO-21-6
+ 36-311.40
77°18'36.27
NAD 83
ADD
Nearest Second
NC-NO-21-7
I 36-31'8.06
177°18'38,41
NAD 83
ADD
Nearest Second
NC-NO-21-8
36°30'50.43
1 77° 19'48.66
NAD 83
I ADD
Nearest Second
NC-NO-21-9
I 36030'6,96"
177020'42.58"
NAD 83
ADD
Nearest Second
NC-NO-21-10
36°30'2.10"
77°20'30.28"
NAD 83
ADD
Nearest Second
NC-NO-21-12
I 36°32'4,61
177°22'19.851
NAD 83
I ADD
Nearest Second
NC-NO-21-14
3602834.81
177°2746.56
I NAD 83
( ADD
Nearest Second
NC-NO-21-19
3602827.15
177°27'51.71
NAD 83
I ADD
Nearest Second
NC-NO-21-20
36027'57.84"
77028'56.36"
NAD 83
ADD
Nearest Second
NC-NO-21-21
36027'52.07"
7702844.90"
NAD 83
ADD
Nearest Second
NC-NO-21-22
36027'55,52" 177°28'38.68"
NAD 83
ADD
Nearest Second
NC-NO-21-23
36028'0,80"
77028'43.83"
NAD 83
ADD
Nearest Second
NC-NO-21-24
36°2$'4.33"
77028'44.03"
NAD 83
ADD
Nearest Second
NC-NO-21-25
36028'4.21"
77028'29.54"
NAD 83
ADD
Nearest Second
NC-NO-21-26
360287.55"
77"28'33.85" (
NAD 83
ADD
Nearest Second
NC-NO-21-27
36"28' 10 20"
77028'43.92"
NAD 83
ADD
Nearest Second
NC-NO-21-29A
36027'50.49
77°28'14.29
NAD 83
ADD
Nearest Second
NC-NO-21-29B I
36027'38.73 177028'16.62
I
NAD 83
ADD
Nearest Second
NC-NO-21-30
36"27 52.90
77028'2,94
NAD 83
ADD
Nearest Second
NC-NO-21-31
36027'53.:28
77027'53,32
NAD 83
ADD
Nearest Second
NC-NO-21-33
36027'50.52
77027'43.95
NAD 83
ADD
Nearest Second
NC-NO-21-35
36027'46.92
77027'30,81
NAD 83
ADD
Nearest Second
NC-NO-21-36
36027'38.26
77"28'0.29
NAD 83
ADD
Nearest Second
FORM: LASC 06-16 Page 5

LAND APPLICATION SITE CERTIFICATION
NC-NO-21-38
36°2729.09
77°28'0.02
NAD 83
ADD
Nearest Second
NC-NO-21-39
36°2724.10
( 77°28'0.81
I NAD 83
I ADD
Nearest Second
NC-NO-21-40
36°2721.29
177°27'58,65
NAD 83
ADD
Nearest Second
NC-NO-21-41
I 36°2720.06
I 77°27'57.91
NAD 83
ADD
Nearest Second
NC-NO-21-42
3602719.37
I 77027'56.10
NAD 83
ADD
Nearest Second
NC-NO-21-43
36°272.87
77-28'11.37
NAD 83
ADD
Nearest Second
NC-NO-21-44
36°26'51,71
I 77028'14.49
NAD 83
ADD
Nearest Second
NC-NO-21-52
I 360277.93
77-27`39.93
NAD 83
ADD
Nearest Second
NC-NO-21-53
36027'42.80"
7702723.39"
NAD 83
ADD
Nearest Second
NC-NO-21-54
36027'39.44"
7702718.07"
NAD 83
ADD
Nearest Second
NC-NO-21-55
136027'40.18"
77027'14.45"
I NAD 83
ADD
Nearest Second
NC-NO-21-56
I 3602734.27
7702725.26"
NAD 83
ADD
Nearest Second
NC-NO-21-57
136°2T43.08,"
77026'51.52"
NAD 83
ADD
Nearest Second
Ramsey Creek, 25-4-8-1
C;NSW
NC-NO-21-58
I 36030'0.29"
77020'4.47"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1
C
NC-NO-21-59
+ 3602758.94"
77027'58.57"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1
C'
NC-NO-21-60
I 36028'5.78"
77028'13.56"
I NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1
C
NC-NO-21-61
136°28' 12.74"
77028'29.81"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1
C
NC-NO-21-62 I
36028'9.68"
77028'21.76"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1
C
NC-NO-21-63 136027'32.95"
77027'14.61"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1'
C
NC-NO-21-64 I
3602728.10"
770275.74"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1'
C
NC-NO-21-65
36°27' 19.07"
77°2712.90"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1
C
NC-NO-21-66
360279.14"
77°2723.88"
NAD 83
ADD
Nearest Second
Gumberry Swamp, 23-32-1
C
NC-NO-21-67
36026' 16.32" 177025'46.07"
NAD 83
ADD
Nearest Second
Ramsey Creek, 25-4-8-1
Q
NC-NO-21-68
36025'44.73"
77024'58.71"
NAD 83
ADD
Nearest Second
Ramsey Creek, 25-4-8-1
C;NSW
NC-NO-21-69
36025'34.11"
77024'42.63"
NAD 83
ADD
Nearest Second
Ramsey Creek 25-4-8-1!
C;NSW
NC-NO-21-70
3602541.41"
77024'15.62"
NAD 83
ADD
Nearest Second
Wiccacanee Swamp, 25-4-8-1.5
C;NSW
NC-NO-21-71
36025'28 27
77024'28.14"
NAD 83
ADD
Nearest Second
Wiccacanee Swamp, 25-4-8-1.5
C;NSW
FORM: LASC 06-16 Page 6

LAND APPLICATION SITE CERTIFICATION
NC-NO-21-72 36025'16.91" 77024'40.59 NAD 83 ADD Nearest Second Wiccacanee Swamp, 25-4-8-1.5 C; NSW
Note: Please keep the site information (I.) and waterbody information (IL) of the same field on the same page.
FORM: LASC 06-16 Page 7

Im
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicants name: Roanoke Rapids Sanitary District
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-HX-6-2
N
Row Crop
Animal Feed
NC-HX-6-3
N
Row Crop
Animal Feed
FORM: LOA 06-16 Pagel of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to eachplanting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surfacewater, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested fora 38-month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
III. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
® A re -defined compliance boundary is needed for field(s) ID: NC-HX-6-3
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new nroaram;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
�j
Landowner name: r p / �1 �� / �L A4ti /' //J
Address: / (�7(�'- } ��t/ hoc;/0j �-K�,
City: i'�t� State: A/6 Zip: .7S7"
Phone: -E-mail address:
- ` Signature: Date: _-
NORTH CAROLINA,Iax _ COUNTY
I, the undersigned Notary Public do hereby certify that ? memav t 1"l 16Le[ 0M-9.
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the O
day of —E6Y t , 20
Signature and seal:
My commission expires
Lessee's/Operator's Certification:
1 certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature: Date:
FORM: LOA 06-16 Page 3 of

VICINITY MAP
- _
r _
4
w
„T
�z
r
C
GRAPHIC SCALE
1" = 4,000'
4,000' 0 4,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-HX-06
Fields 2-3

APPLICATION MAP
LEGEND
UNSUITABLE AREA
APPLICATION AREA
WATER
— — — — — — PRIVATE ROAD
'
ONSITE HOUSE GRAPHIC SCALE
-- — - -- STREAM
1" = 660'
OFFSITE HOUSE 660' o 660'
— — DRAIN
OUTBUILDING
FENCE
WELL
PROPERTY LINE
O
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-HX-06
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Field 2

APPLICATION MAP
LEGEND
UNSUITABLE AREA
APPLICATION AREA
O
WATER
— — — — — — PRIVATE ROAD
GRAPHIC SCALE
•
ONSITE HOUSE 1" - 660'
- - - - STREAM
OFFSITE HOUSE 660' o 660'
DRAIN
OUTBUILDING
-X X--X— FENCE
WELL
PROPERTY LINE
O
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-HX-06
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Field 3

SOIL SURVEY
GRAPHIC SCALE
1" = 800'
800, 0 800,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closestto the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-HX-06
Field 2

SOIL SURVEY
GRAPHIC SCALE
1"=800'
800' 0 800'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
NC-HX-06
Field 3
locations are approximate.

TOPOGRAPHIC MAP
`°w�'#, ....
„� ..,..�,w, '♦
�-� *....,-«...er�'�" j
f�,7 may,.
{{
i'4
F •(j�M�'+I yam«,
a.„,++�,....�✓
�
a
�yY 1"+y�5
t
0 3�
415
l 4..
l •
at � ,"�.. [f � � C''
mow.."'(?. j
�3 ��.-.... y�
,.="g 'may i �1; � ��
�
�✓✓✓jjj � x
GRAPHIC SCALE
1" = 800'
800,
0 800,
The
compliance boundary is established either 250 ft from the residuals
application area or 50 feetwithin
N C-HX-06
in the property boundary, whichever is closest to the application area.
The review boundary is established
midway between the compliance boundary and the perimeter of the
locations are approximate.
residuals application area.
All
Field 2

TOPOGRAPHIC MAP
31
LAi
f j �l • "" r F` e .?.C.N
# 5pP j f �.
fi
oi- -
4i,
t�� µ �}r ^`•,•,_.....•.r"' �F �F � "°_,,,,�,,.,,,„�
�'� � 5 �''�� ifs f'� � ` ! f ;_ '�� �'•...._. _..,,'� j� t
i„ �„4.,,."r"`3 4 ! "».✓"'r _...,•,� �.�. (f �4 c ....�..-..e.,.,�\.,,: ors"`' if' �((
GRAPHIC SCALE
1" = 800'
800' 0 800'
The compliance boundary is established either 250 ftfrom the residuals application area or 50 feet within
N C-HX-06
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
Field 3

GRAPHIC SCALE
1" = 4,000'
4,000' 0 4,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-HX-07
Field 1

APPLICATION MAP
LEGEND
UNSUITABLE AREA
APPLICATION AREA
WATER
— — — — — — PRIVATE ROAD
GRAPHIC SCALE
ONSITE HOUSE
— — — — STREAM
1" = 660'
OFFSITE HOUSE 660' o 660'
DRAIN
_
OUTBUILDING
FENCE
WELL
PROPERTY LINE
O
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-H X-07
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Field

TOPOGRAPHIC MAP
V.
UJfl
IJ
t
1 m
GRAPHIC SCALE
1" = 800'
800' 0 800'
The
compliance boundary is established either 250 ftfrom the residuals application area or 50 feetwithin
N C-HX-07
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
Field 1

SOIL SURVEY
GRAPHIC SCALE
1" = 800'
The compliance boundary is established either 250 ft from the residuals application area or 50 feetwithin
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
NC-HX-07
Field 1
locations are approximate.

Dwk
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 —LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
suuportin documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Roanoke Rapids Sanitary District
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-NO-10-2
N
Pasture
Animal Feed
NC-NO-10-3
N
Pasture
Animal Feed
FORM: LOA 06-16 Pagel of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
I1. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food cropswith harvested parts below the surface of the land shall not be harvested for a 3 8-month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
HI.ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
® A re -defined compliance boundary is needed for field(s) ID: NC-NO-10-2, NC-NO-10-3
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: . is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Roanoke Rapids Sanitary District
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-WR-3-2
N
Pasture
Animal Feed
FORM: LOA 06-16 Pagel of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise pen -nit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will infonn the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during aresiduals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5_ Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following aresiduals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
III.ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15 A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
® A re -defined compliance boundary is needed for Iield(s) ID: NC-"-3-2
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: , is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

VICINITY MAP
GRAPHIC SCALE
1" = 4,000'
4,000' 0 4,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area, All
locations are approximate.
NC-WR-03
Field 2

APPLICATION MAP
LEGEND
UNSUITABLE AREA
APPLICATION AREA
O
WATER
— — — — — — PRIVATE ROAD
! +
ONSITE HOUSE
— — STREAM
.
OFFSITE HOUSE
— DRAIN
OUTBUILDING
FENCE
(
WELL
PROPERTY LINE
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1" = 660'
660' 0 660'
N C-WR-03
Field 2

TOPOGRAPHIC MAP
GRAPHIC SCALE
1" = 800'
1
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within I N C-WR-03
in the property boundary, whichever is closest tothe application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Field 2

SOIL SURVEY
GRAPHIC SCALE
1" = 800'
800, 0 800,
The compliance boundary is established either 250 ftfrom the residuals application area or 50 feet within N C-WR-O
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Field 2

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources
15A NCAC 02T .1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Roanoke Rapids Sanitary District
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-NO-12-1
N
Pasture
Animal Feed
NC-NO-12-2
N
Pasture
Animal Feed
FORM: LOA 06-16 Pagel of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee andlor the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
III.ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
® A re -defined compliance boundary is needed for field(s) ID: NC-NO-12-1
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new promm;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name:2C,Q
Address: 1 3 3 `( i)> i2 cj-
City: State: Zip:
Phone: 4_37 3 S!U 3 E-mail address: D Q c /(V v 0
Signature: Qi Z 1 a Date:
NORTH CAROLINA, a'r-I►'�0,m Oh COUNTY
I, the undersigned Notary Public do hereby certify that L-att a. F_ws" w
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my'h'and�and official seal this the ,
day of
Signature and seal:
My commission expires: 3° 2�
Lessee's/Operator's Certification:
1202— 1
oft CPA* No
WftMMWM
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature:
Date:
FORM: LOA 06-16 Page 3 of 3

IM
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 —LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the. Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicants name: Roanoke Rapids Sanitary District
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
Site/Field ID
Lease
Land Use or
Intended Use of Crops
Residuals Source
Special note
(no-till/over-seed/
(yes/no)
Cropping Patterns
(optional)
pasture)
NC-NO-21-1
Y
Row Crop
Animal Feed
NC-NO-21-2
Y
Row Crop
Animal Feed
NC-NO-21-3
Y
Row Crop
Animal Feed
NC-NO-21-4
Y
Row Crop
Animal Feed
NC-NO-21-5
Y
Row Crop
Animal Feed
NC-NO-21-6
Y
Row Crop
Animal Feed
NC-NO-21-7
Y
Row Crop
Animal Feed
FORM: LOA 06-16 Pagel of 3

1. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-monthperiod following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
M. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
® A re -defined compliance boundary is needed for field(s) ID: NC-NO-21-6
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the Ileld(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two co ies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Roanoke Rapids Sanitary District
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
Site/Field ID
Lease
Land Use or
Intended Use of Crops
Residuals Source
Special note
(no-till/over-seed/
(yes/no)
Cropping Patterns
(optional)
pasture)
NC-NO-21-20
Y
Row Crop I
Animal Feed
NC-NO-21-21
Y
Row Crop
I Animal Feed
NC-NO-21-22
Y
Row Crop
I Animal Feed
NC-NO-21-23
Y
Row Crop
Animal Feed
NC-NO-21-24
Y
Row Crop
Animal Feed
NC-NO-21-25
Y
Row Crop
Animal Feed
NC-NO-21-26
Y
Row Crop
Animal Feed
NC-NO-21-27
Y
Row Crop
Animal Feed
FORM: LOA 06-16 Pagel of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
H. RESTRICTIONS:
1. Appropriate measures must betaken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that wilI be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
III. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells withinthe compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
® A re -defined compliance boundary is needed for field(s) ID: NC-NO-21 22, NC-NO-21-27
(Please include the rationale fbr the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV.ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: , is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NC_ AC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
® Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Roanoke Rapids Sanitary District
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
Site/Field ID
Lease
Land Use or
Intended Use of Crops
Residuals Source
Special note
(no-till/over-seed/
(yes/no)
Cropping Patterns
(optional)
pasture)
NC-NO-21-1
Y
Row Crop
Animal Feed
NC-NO-21-2
Y
Row Crop
Animal Feed
Y
NC-NO-21-3
Row Crop
Animal Feed
NC-NO-21-4
Y
Row Crop
Animal Feed
NC-NO-21-5
Y
Row Crop
Animal Feed
NC-NO-21-6
Y
Row Crop
Animal Feed
NC-NO-21-7
Y
Row Crop
Animal Feed
FORM: LOA 06-16 Pagel of 3

NC-NO-21-8
Y
Row Crop
Animal Feed
NC-NO-21-9
Y
Row Crop
Animal Feed
Y
LNC-NO-21-10
Row Crop
Animal Feed
NC-NO-21-12
Y
Row Crop
Animal Feed
NC-NO-21-14
Y
Row Crop
Animal Feed
LNC-NO-21-19
Y
Row Crop
Animal Feed
L NC-NO-21-29A
Y
Row Crop
Animal Feed
NC-NO-21-29B I
Y
Row Crop
Animal Feed
NC-NO-21-30
Y
Row Crop I
Animal Feed
NC-NO-21-31
Y
Row Crop
Animal Feed
NC-NO-21-33
Y
Row Crop
Animal Feed
NC-NO-21-35
I Y
Row Crop
Animal Feed
L NC-NO-21-36
I Y
Row Crop
I Animal Feed
I
I 1
Y
NC-NO-21-38
Row Crop
I Animal Feed
L NC-NO-21-39
Y
Row Crop
I Animal Feed
NC-NO-21-40
Y
Row Crop
Animal Feed
NC-NO-21-41
Y
Row Crop
Animal Feed
NC-NO-21-42
Y
Row Crop
Animal Feed
NC-NO-21-43
Y
Row Crop
Animal Feed
NC-NO-21-44
Y
Row Crop
Animal Feed
NC-NO-21-52
Y
Row Crop
Animal Feed
NC-NO-21-57
Y
Row Crop
Animal Feed
NC-NO-21-58
Y
Row Crop
Animal Feed
NC-NO-21-62
Y
Row Crop
Animal Feed
FORM: LOA 06-16 Page 2 of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with infbn nation and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) priorto each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
U. RESTRICTIONS:
1. Appropriate measures must betaken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used f'orgrazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 3 8-month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
III. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
® A re -defined compliance boundary is needed for field(s) ID: NC-NO-21-33
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV.ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
Landowner's Certification:
F(1RAA- T 0A nrA-lh P.ap 2 nf2

CUMULATIVE METAL LOADINGS (LBS/AC) AS OF 12/31/2020
The cumulative metals for this report come from HISTORY records (i.e. the monthly monitoring process has been completed for the State and County where the Fields are located)
In cases where a trace metal lab result was Not Reported to Synagro or tracking of metal loading was Not Required the loading on the report is displayed as "MR"
FIELDID Last Date Applied AS CD CR CU PS HG MO NI SE ZN
NC-HX-00009-0-0007- 09112/2012 0.28111 0.16120 3.13939 15.17107 4.56913 0.08773 1.01050 1.15648 0.14182 58.11200
Report Date/Time: 1/26/2021 1:46:42 PM Page 1 of 1