WQ0042647_More Information (Received)_20220114

REGISTER OF DEEDS
Sharon A. Davis
Durham County, NC
2021 Dec17 04:04:18PM
BK:9564 PG:515-516
AGREEMENT
FEE: $26.00
INSTRUMENT # 2021064422
DPRUETTE
Hum tIIi l l l l I Ill�li III III
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTWATER SYSTEM WAIVER
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
I, Caitlin M. Kempski and Samuel L. Milstead, certify that I am a deeded owner of the property located at:
Address: 220 Riley Drive Parcel No.: 160328
City: Durham
State: NC Zip Code: 27704 County: Durham
Furthermore, I certify that I am authorized to make decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Permittee listed on the following
page.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
application of wastewater effluent as near as feet from my property line.
El I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from 200 feet to 100 feet, thereby allowing the
application of wastewater effluent as near as 100 feet from my residence.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as _ feet from my property line.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as feet from my residence.
Signature:
FORM: NDWSW 03-17
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Date: 1(2//0�oi0a
Page 1 of 2
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Applicant/Permittee: Caitlin M. Kempski and Samuel L. Milstead
Address: 220 Riley Drive
City: Durham
Parcel No.: 160328
State: NC Zip Code: 27704
County: Durham
NORTH CAROLINA, AY h coon COUNTY
I, Gree;-o1& Laaw, , a Notary Public for V\16.1 County, North Carolina,
S0.xy1Ut,1 L- IV1i140cd .4
do hereby certify that C X4\1tll 'M. VQ0kkrYikl personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the enday of (112;iQV ,AI.
SEAL,
GRAZIELLA LA ROSA
Notary Public
Wake Co., North Car li -
My Commission Expires: \a It a1I5
My commission expires l a )) D 1 9 p J
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded
waiver shall be sent to the following address:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDWSW 03-17 Page 2 of 2