WQ0000520_Renewal Application Part 3_20220203

Non -Discharge Branch Upload/Submittal Form
NORTH CAROLINA
EnWrvnmemfal Qualify
Version 2 - Revised June 23, 2020
Initial Review
Reviewer
Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0000520
Applicant/Permittee City of Burlington
Applicant/Permittee Address PO Box 1358 Burlington, NC 27216
Is the owner in BIMS? Yes No Is the facility in BIMS? Yes No
Owner Type
Facility Name
County
Fee Category
Is this a complete application?*
Yes No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review by the hydrogeologist?*
Regional Office
CO Reviewer
Admin Reviewer
Municipal
City of Burlington Class B Residuals Program
Alamance
Yes No
Fee Amount $395
Complete App Date 02/03/2022
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Admin
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
Name* Robert N Roth
Email Address*
[e-mail]
Project Information
Application/Document Type *
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
3364034324
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
Residual Annual Report
Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type: *
Permit Number: *
Wastewater Irrigation
Other Wastewater
Closed -Loop Recycle
Single -Family Residence Wastewater
Irrigation
WQ0000520
Has Current Existing permit number
Applicant/Permittee* City of Burlington
Applicant/Permittee Address* PO Box 1358 Burlington, NC 27216
Facility Name* City of Burlington Class B Residuals Program
Please provide comments/notes on your current submittal below.
Part3of3
High -Rate Infiltration
Reclaimed Water
Residuals
Other
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here. *
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
City of Burlington Rewewal W00000520_Part3.pdf 205.29MB
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order and
made payable to the North Carolina Department of Environmental Quality (NCDEQ).
I also confirm that the uploaded document is a single PDF with all parts of the
application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature

Submission Date 1/31/2022

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purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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URLINGTON
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Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
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DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
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DENR FORM FSF (12/2006)

EN NOT APPLICABLE.
PLACE A "N/A" IN A BLANK OR BOX
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
00
Annual Dry Tons Applied:
Land Owner:
Cation Exchange Capacity (non 503):
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DENR FORM FSF (12/2006)

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DENR FORM FSF (12/200

00
Acres Utilized:
00
WQ Permit #:
City of Burlington
Facility Name:
tr
00
Acres Permitted:
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East Burlington
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East Burlington
East Burlington
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Signature of Land Applier
DENR FORM FSF (12/2006)

EN NOT APPLICABLE.
PLACE A "N/A" IN A BLANK OR BOX
Acres Utilized:
0,
WQ Permit #:
C.)
Facility Name:
N
Acres Permitted:
1/40
•
Annual Dry Tons Applied:
5
Land Owner:
O
Cation Exchange Capacity (non 503):
Predominant Soil Series:
David Ridlin
0
Name of Crop Type
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Application
Crop 2 I
ILime Applied
Date lbs/ac
CEC 660
Attachment I
P,
O
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(lbs/acre)
N
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N
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a
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v
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U
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0.336
0.453
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•
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130000
175500
0
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Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
Annual Dry Tons Applied:
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
David Ridlin
0
2
z
a
go
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z
Name of Crop Type
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lbs/ac
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U
=
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( lbs/acre)
N
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0-
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o
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--
N
c
w
0O
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rn
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m
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0
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n Rate***
M
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0
v
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Volatilization
Rate**
Ln
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0
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oA
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N
0
N
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0M
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71-
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N
0.000
0.000
O
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0.102
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.
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
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Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
156000 I
©
1560001
o
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Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
O
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
h
Annual Dry Tons Applied:
ess
w
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Frank Small
E
z
tow
0
ID
E
z
0
U
Name of Crop Type
Receiving Residual
Application
N
0
0
C.)
Lime Applied I
lbs/ac
— '0.
O j
as
=
0
L1
0
W
0
c4
0
Pa
0
Gq
PAN Applied
(lbs/acre)
GL
O
C,
Z
d
z
Q'
Z
Q4
Z
Q
Z
Q
Z
O
O
O
O
O
O
O
O
O
o
O
O
O
o
O
O
O
0
O
O
0
0
O
O
O
0
O
O
O
0
O
O
—
G+
O
U
N
t�
N
71'
v-,
0
Cr;
^,
0
N
�
0
.0
D1
0
.0
o,
0
0
0
O
0
0
0
O
0
0
0
O
0
0
O
co
0
0
O
co
0
0
O
O
0
O
O
O
a- y m
y00
4„ "d 'y Y
rn
z z E
O
0-
O
v
O
v
O
0-
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
a
p
71-
v
N
O
N
c i
0,
m
°O
`n
m
m
O1
co
N
Ammonia Y
m
Nitrogen E
o
o
r
0
0
0
0
0
o
0
o
o
o
ti
y
on
m
N
p
o
oo
.N-i
O
.—
.�-.
O
Q,
00
0,
H s-
O
0
0
O
m
p
0
0
O
en
0
0
0
O
en
0
0
0
O
en
0
0
0
(-I
N
0
0
0
r
N
Z
v,
o0
o
o
Q
0
71-
m
Mineralizatio
n Rate***
en
0
en
0
en
0
en
0
en
0
en_
0
o
o
0
N
0
Volatilization
Rate**
in
0
v-1
0
i,
n
0
v,
0
v,,-,
0
04
.`ri '
o
p
o
o
0
0-
O
0
4,-,
.-.
Application
Method*
va
v)
up
v)
v)
vz
"fl
m
O
p
.--+
O
,_.
O
O
N
• o.• N
v N ..., t
�r c
0.
_
in
V.
_
v1
V.
_
ul
V.
_
v)
V.
_
rn
V.
_
u>
V1:1.
U
0.173
4.118
N
4
8 0 ..-'
up U Q /
Q
i-a
Q
Q
Q
Q
1
g
U
00
a1
in
o
00
r
a;
m
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington
East Burlington
East Burlington
East Burlington
"O
t..)
m
N
O
O
0
oo
O
O
0
O
m
Volume
Applied per
Acre
(Dry Tons/Ac)
00
N
O
.--,
rn
O
0.462
0.426
0.444
0.444
O
O
O
0.000
0
O
O
0
O
O
0
co
O
0
O
O
0
O
O
d
0.023
p
m
•—
•
o
0
CID
N
v1
N
v'1
N
kr;
N
to
O
N
O
V',
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds Gallons
32500 I
00SIL
84500
78000
84500
84500
I 435500
0
0
7� TAT
•-1�uoJ Y
.10 Q
N
n
N
o
N_
;n
o
N
.n
N
N
vi
Q
0
Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
N
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
Annual Dry Tons Applied:
z
Land Owner:
Cation Exchange Capacity (non 503):
C7
Predominant Soil Series:
David Ridlin
iy
b�+
Lr
CL
0
E
z
Cr
O
O,
E
z
Name of Crop Type
Receiving Residual
Application
Crop 2 I
Lime Applied I
U
m
2
1420 I
Q
W
U
o
U
_Ina
Co
PAN Applied
( lbs/acre)
N
i]r
OO
U
.e
z
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O,o
O
O
O
—
0
~
CL
O
e3
N
'"
d:
C4
co
0
o
0
O
o
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
O
0
0
O
O
0
0
O
o
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
N
'''
m
-0 C'. Y pn
• °Z E
M
CLI
O
71-
0
N.
Le-,
r,
c i
,n
N
,,
vi
o
o
,n
oo
00
o,
7
N
Ammonia 0,O
CDO
Nitrogen E
o
(/D
M
O
o
t�
O
0
O
O
0
000
p)
H E
O
O
N
Z
en
N
o
N
N
0
M
M
0
M
Mineralizatio
n Rate***
c.,
cn
o
0
VD
o
0
m
0
Volatilization
Rate**
in
0
to
r"
o
0
0
0
0
0
Application
Method*In
,0
M
N
O
O
r-
0
N
o
O
0,
N
0
N
,A. N • rn
U rn a3
s
x G
as
_
v
o
CN1
0,
.o o
Q
Q
_
O
O
N
Oo
r.
cc
en
'�
U
en
N
O
O
,..0
O
M
O
O
0,
to
O
O
M
N
N
N
o
O
O
O
O
O
O
O
O
O
O
O
0.000
0.000
.
0.023
0.073
sc
©
O
i
O
to
_
N
U
ed
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1 st/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
182000
O
O
01 182000
quo
zo aria
N
N
o
F
Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
WQ Permit #:
73
•
L)
Facility Name:
Acres Permitted:
Annual Dry Tons Applied:
5
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
David Ridlin
et
C+,
z
41
z
0
U
E
z
0
O
Name of Crop Type
Receiving Residual
Application
Crop 2
Lime Applied
U
ct
cn
s3
"
U
0
U
0+
O
U
cu
Y
A
'b
•-
"�
sa.
0
Q
z
.,
z^zO
Q
0
co
O
0
o
O
O
o
O
O
O
o
O
O
O
o
co
O
O
O
co
O
O
o
O
O
O
0
co
O
O
0
co
co
O
o
O
O
O
o
O4"
O
O4.so-�
—
p
".
O
u
�"
_
00
o0
M
,'n.+
O
O
0
O
O
co
0
co
O
co
0
O
CD
co
0
co
0
O
CD
co
0
O
co
0
O
o
co
0
O
0
0
co
o
O
0
O
Cf.,
M
y
z z
o
v
0
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
py
v
Ammonia _
er,o
Nitrogen E
o
N-
0
0
o
o
N
g
N
,so
r`
o
w
4-
vl-
N
p,
s
O
o
o
CD
0
0
N
o
o
y
V)
O
o
O
O
,_,
O
c,
x,
Mineralizatio
n Rate***
M
O
M
O
M
O
Z
CA
co
0
o
V)
0
VD
v-,
0
v
C-
'
Volatilization
Rate**
to
0
kn
0
0
o
0
0
o
CA
0
Application
Method*
be
x000
0
o
0
N
0
P N N_
x.2
w
V
_
V
V
p"
O
o
M
0
o
N
a
V1 e 6' t':'
Q
i=i
L2
Q
Cr
0.151
00
(-A
M
3.440 I
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
South Burlington
East Burlington
South Burlington
U
V)
M
M
O
'0
N
N
r
^'
VD
v,
00
M
.M-i
-or—
U.
0
O
00
0
O
rn
o
O
�
M
Volume
Applied per
Acre
(Dry Tons/Ac)
0.281
0.242
Cr,
0
0.000
0
CDv o
0
00
o
0
0.000
0.000
0
o
0
0.000
0.000
0.000
0.000
E,
0
0
0
0
0
^
0
t°
M
b
0
oo
N
M
N
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds Gallons
97500
65000
195000
o
0
0
M
0
0
-wow
zo al1Q
o
b,
o
b.
v,
H
O
Signature of Land Applier
DENR FORM FSF

DWR
Division or 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):
Xi 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.
[41 Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
j 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: City of Burlington
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:
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-AM-118-2,3,4
No
Corn/Soybeans
Feed
NC-AM-118-5,7,8,9
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 9
(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

WITNESS my hand and official sealthis the
day of
Signature and seal:
My commission expires:
Lessee's/Operator'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 anothermunicipahty, 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. )�
Landownername: � MOV\ �GrY+-C y S
Address: /Plof p
A Sl +t4S Trat
/
City: N7ii�y State: Ate- Zip: :i 7;. 9.?"
Phone: 3 J&-a-L 0r 3 E-mail address:
Signature: ;An --
NORTH CAROLINA, 1 tACUNNOUNCfL COUNTY
I, the undersigned Notary Public do hereby certify that
Date:
C(,ori+e nos
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
o0‘
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: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
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: �� �1�Cs..c_ 44-1f--11-C-
Signature:
^ l
Date: / 2.1/r/2A9 Z.I
FORM: LOA 06-16 Page 3 of 3

DWR
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: City of Burlington
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:
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-AM-118-9
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 9
(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

\)(
Signature:
State: ivy Zip: pi 7A 9F
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
agreementwith anothermunicipality, contractor, or other permitted entity. Furthermore, Icertify 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:
S y'viat Aol-, r5
Address: i7 G'o S' ep he %15 Th.et(' (
City: L,r
Phone: E-mail address:
Date: 1 A'lo ` t
NORTH CAROLINA, f d O 4'Ye&r . C-Q .. COUNTY
I, the undersigned Notary Public do hereby certify that , Ya..oyx'S
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
day of 7Der."—en
Signature and seal: 4?&(1\400, R
My commission expires:
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations a ' ' as specified herein.
.rLessee/operator name:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing, official name: S ('i t- I tQ
Signature:
Date: /,L//S/7.1) s-/
FORM: LOA 06-16 Page 3 of 3

Site: NC-AM-118; Fields 2-5, 7-9
Vicinity Map
1 in = 6,000 ft
0
ALAMANCE
CHATHAM "
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
DNA
ITY
Town of Cary, Alamance County, State,gf North Carolina DOT, Esri;`HERE,
Garmin, INCREMENT P,"USGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site:NC-AM-118; Fields 2-5, 7-9
Application Area Map
1 in = 660 ft
BCity of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
Site Boundary
Q Property Line
IApplication Area
Unsuitable
X — Fence
V/1
▪ S.W.A.
® On Site House
III Off Site House
J Outbuildings
On Site Well
-0- Off Site Well
--- Streams
Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
I 1
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-118; Fields 2-5, 7-9
City of
URLINGTON
GIS Division
Date: 1 /1112022
*Note: Acreage calculated in GIS
Legend
]Site Boundary
Q Property Line
4 4 (Application Area
Unsuitable
X — Fence
V/I
• S.W.A.
On Site House
▪ Off Site House
L Outbuildings
On Site Well
-0- Off Site Well
-- Streams
Drains
I 1
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard for the verification of the information contained within this map.
Application Area Map
1 in = 600 ft
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted

Owner Name: STEPHENS SIMON ROSS JR
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Site kW-AM-1)1'a
Soil Map
1 in = 1,000 ft
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0 Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
City ofTO]/�
JRLI GN
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
.74
N
3
WQ Permit #:
City of Burlington
Facility Name:
N
Acres Permitted:
00
d
N
Annual Dry Tons Applied:
Simon Stephens
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Simon Stephens
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N
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(NPDES #, WQ#,
Fert., Animal
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South Burlington
East Burlington
East Burlington
East Burlington
Residuals Appl
U
O
0
N
N
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00
MM.-+
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Permitted C. P. L. R.****
IPertnit PAN Limit 1st/2nd Crop
Volume applied
(enter one) Solids/
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Cu. Yds Gallons
84500
52000
45500
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Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
EN NOT APPLICABLE.
PLACE A "N/A" IN A BLANK OR BOX
Acres Utilized:
to
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
00
•
00
a;
d-
Annual Dry Tons Applied:
Simon Stephens
Land Owner:
0
Cation Exchange Capacity (non 503):
0
Predominant Soil Series:
Simon Stephens
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a
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N
N
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No.
M
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N
0,
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South Burlington
South Burlington
'G
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•
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(enter one) Solids/
Liquid
Cu. Yds I Gallons
45500
123500
65000
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Signature of Land Applier
DENR FORM FSF (12/2006)

Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
d-
Acres Permitted:
N
Annual Dry Tons Applied:
Simon Stephens
Land Owner:
O
Cation Exchange Capacity (non 503):
a
o
Predominant Soil Series:
Simon Stephens
a
z
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Name of Crop Type
Receiving Residual
Application
Crop 2
I Lime Applied I
U
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( lbs/acre)
N
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Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
O
0
N
0
o
M
v
N
Ammonia
Nitrogen E
co
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O
O
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oo
O
0
N
O
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(NPDES #, WQ#,
Pert., Animal
Waste, etc)
South Burlington I
U
-
0
000
a•
m
Volume
Applied per
Acre
(Dry Tons/Ac)
0
N
,--,
o
O
O
0
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0.000
0.000
0
0
O
0.000
0.000
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Annuallbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1 st/2nd Crop
•
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
162500 I
0
l 162500
0
O
uo u�
Jo NeU
te',
d
H
0
F
ation Method:
Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL L
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
r`
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
00
Cip
oo
oo
N
Annual Dry Tons Applied:
Simon Stephens
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Simon Stephens
E
z
a)
5
z
1-1
Jr
U
Name of Crop Type
Receiving Residual
Application
Crop 2 1
I Lime Applied I
lbs/ac
V
O
L
U
W
V
4..
PAN Applied
(lbs/acre)
N
Sa.
Q
z
z
z
z
0
0
0
O
©
0
0
O
©
0
0
O
©
0
0
O
©
0
0
O
©
0
0
O
O
0
0
O
O
0
0
O
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0
0
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0
0
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0
0
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0
0
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0
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0
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0
©
0
o
cc
© 0
o
N
g ,_, 0,
z �z
N
(r3
r
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
a
rn
O
T
•
,�
O
N
N
boc
o"'o
ry'
o
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N
N
Ammonia -
rn
Nitrogen E
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gl
N
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N
O
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p,
aq
4)41
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0
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N
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i`
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Mineraiizatio
n Rate***
en
o
en
o
O
N
o
b
N
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rn
,n
0
Volatilization
Rate**
w,
o
6
a.
en
o
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00
71"
o
0
Application
Method*
O
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N
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V
V
4.2182
M
Lrl
°J
O
LJl
cc
00
o
rn
©
o
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
South Burlington
East Burlington
'O
U
©
O
O
00
-O
o
o
.-.
0
m
Volume
Applied per
Acre
(Dry Tons/Ac)
00
"n
-OOoo
N
rn
©
0
©
0
©
0
0.000
0.000
0.000
0.000
©
0
O000
©
0
©
0
©
0
en-
o
0
.-,
o
©
cn
c
M
00
4
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1 st/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
97500
45500
I 143000
©
0
ipuow
_TO MG
o
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0
H
y
cos 4-4
Set
.54
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*** Mineralization Rates: C
Signature of Land Applier
DENR FORM FSF

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BL
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
-47
0
O'
WQ Permit #:
City of Burlington
Facility Name:
Ir
Acres Permitted:
CC
Annual Dry Tons Applied:
Simon Stephens
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Simon Stephens
E
z
a
E
z
Name of Crop Type
Receiving Residual
Application
Crop 2 I
I Lime Applied I
c)
ct
211
U
V.
w
PAN Applied
(lbs/acre)
t3.
O
(,
z
z
z
O
O
O
O
O
O
O
O
o
o
O
co
O
0
O
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0
O
O
O
0
0
O
O
0
0
O
O
CO CO0
O
CO
0
O
CO
0
0
O
0
0
0
O
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0
0
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�.
O
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0
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0
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0
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0
0
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0
0
O
O
0
0
o
O
0
0
O
.
N 41
: i.
E
N
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
a
0
V1
,,o,z
o
cc)CAAmmonia
_.
N
d
`\
Nitrogen E
O
o
o
M
o
o
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0 •0
r
0
00
aG rn
E- E
N
o•
0
0
kn
0
M
Mineralizatio
n Rate***
c
J
M
o
o
cc
0
0
Vo1Rate**ion
o
Q
oc
x
o
o
-
0o
o
O
Application
Method*
O
O
O
c
P. a
v
V.x
u
0
o
2.5624
N
ry
I
o o
A
A
A
u
cc
PP
0
cn
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
South Burlington
East Burlington
U
o
0
0
O
o
O
v
M
Volume
Applied per
Acre
(Dry Tons/Ac)
a
Q,
CA
coo
0
0
0
0
0
0
0
0
0.000
0
0
0
0.000
0.000
0.000
0
0
0
0
o
0
0
o
0
0
o
0
cA
Q
,-
o
O
I 0.0694
1 0.084
1 36
'd
c o
cn
0
m
c
4
Annuallbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1st/2nd Crop
•
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
52000
26000
0
I 78000
0
TUO gJA
10 aT1Q
-
0
H
ignature of Land Applier
DENR FORM FSF (12/2006)

PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
00
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
00
Annual Dry Tons Applied:
Simon Stephens
Land Owner:
Cation Exchange Capacity (non 503):
ca
v
Predominant Soil Series:
Simon Stephens
ci
E
z
sci
)
U
5
z
Crop Type
g Residual
ication
Crop 2 I
I Lime Applied
U
o
A
4.
N
00
0
Q
z
O
O
O
o
O
0
O
0
O
0
0
o
O
0
O
O
O
0
O
o
O
0
0
0
O
0
0
0
O
0
O
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
—
^i
^"
N
PAN A
( lbs/
Cr,
o-
0
O
0
0
0
O
0
00
o
O
0
0
O
00
0
0
O
06
0
O
0
0
O
0
0
0
O
0
0
0
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0
0
0
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0
0
0
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0
0
0°
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0
0
Z %~
N
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o
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0°
'n
00
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cn
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N
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0
Oo
,�
Nitrogen E
Residuals Applications totals on FORM FSF supp ( attach FORM FSF sul
kn
O
0
t�
N
0
N
N
0
oo0
CA
'�..i p)
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O
00
°M°
-
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N
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Mineralizatio
n Rate***
M
o
0
o
0
0
Volatilization
Rate**
n
O
o
O
0
0
0
-
Application
Method*
cip
O
0
M
N
N
N
N ti U
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N
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cn
-
—,
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
South Burlington
G U
to
O
0
c
00
0
0
0
M
Volume
Applied per
Acre
(Dry Tons/Ac)
v
01
d'
---1
o
O
0
O
0.000
0.000
0.000
0
O
0
O
0
O
0
O
0.000
0
O
0
O
0.000
0.000
0
O
0
O
o
O
0
O
m
0
O
N
0
0.235
M
0,
-0
o
0
0
tri
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1st/2nd Crop
65000
0
J 650001
Volume
(enter on
Liq
Cu. Yds
O
0
qu
1oy�
Jo ma0
0
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a4
go
go
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N
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Signature of Land Applier
DENR FORM FSF (12/2006)

Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
00
v,
00
o
Annual Dry Tons Applied:
Simon Stephens
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Simon Stephens
44
CL
0
00
a
0)
U
4)
E
z
Cs
Name of Crop Type
Receiving Residual
Application
N
rao
U
I Lime Applied I
lbs/ac
Q
p
s.
U
V
0)
w
U
0)
w
PAN Applied
( lbs/acre)
N
P.
o
Q
r-rz
Q
z
O
o
o
0
O
0
o
0
co
0
0
0
O
0
o
O
O
0
0
O
o
0
o
0
o
0
coo
O
O
0
0
O
0
o
0
O
0
o
0
o
0
o
0
0
0
o
O
—
.Mr
p.
o
o'
N
,,
O1
M
N
O
O
0
O
o
O
0
O
0
O
0
O
0
O
0
O
o
O
0
0
o
O
0
0
O
O
0
0
o
O
0
0
O
o
0
0
o
0
0
0
o
000
0
0
0
0) y
- b ... e
zziri
d0-
I— —I Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
pi
00
M
N
N
`n
o-
`°00
d
v
N
a,
Ammonia o
Nitrogen E
0
0
0
o
r
Co
O
0
0
N
0
0
eno00
0
E E
0
0
rn
0
0 °
°M
Z
o
o
r.
o
•
M
Mineralizatio
n Rate***
M
0
M
0
o
o
0
N
0
d-
0
Volatilization
Rate**
v,
o
,n
o
°c
o
o
0
0
0.'
0
Application
Method*
up
up
a
0
O
w
N
N
Q\
N
N
ti a,
• U N • t
,�+ `rri C
_
V.
_
V
u
N
o
,,O
o;
o1
o;
6)
o O T '8
cn
U iti
Dry
Q
r�'N�
O
N
N
M
N
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
South Burlington
South Burlington
•�
U
NO
O
0
O
O
o
71-
M
Volume
Applied per
Acre
(Dry Tons/Ac)
1.674
N
0,
0
0
0
0
0
O
0
0.000
0
0
O
0
o
O
0
0
O
0
0
O
0
0
o
0.000
O
0
0
0.000
0.026
N
0
N
•0
rn
:-.
o
0
Annuallbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
156000
84500
0
I 240500
0
0
q uo�
zo aVeQ
°°
.
v
vi
a
E.
Signature of Land Applier
DENR FORM FSF

DWR
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: City of Burlington
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:
Site/Field ID
NC-AM-119-1,2
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
o tionai
(optional)
Special note
no-till/over-seed/
pasture)
No
Row
Feed
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.
FORM: LOA 06-16
Page 1 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 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 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.
IILALTERNATIVES 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;
X A re -defined compliance boundary is needed for field(s) ID: 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 program;
(Name of the new program)
FORM: LOA 06-16
Page 2 of 3

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
agreementwith anothermunicipality, contractor, or other permitted entity. Furthermore, I certify thatI 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:
Address: 40(7 s-f'ephenS 7
/ City: State: /�lEi Zip: oZ 7.1 6
L!i
Phone: 3 -3 r-; 6 7 7 E-mail address:
Signature: / /k( l/ - Date: (.2-/l 0 7,10A/
NORTH CAROLINA,OCkarf 4mC'e-• CO JNTY
Public do hereby �.1c ' -
I, the undersigned Notary Y certify that ,^
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and officialsealthis the \ b
day of ,�Xr
Signature and seal: gCLCa.'( • •3.41'""` U
My commission expires: —
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulatlions as specified herein.
,20 ai
NOTAR
PuBLle
•Lessee/operator name:
Address:
City: State: Zip:
Phone: E-mail address:
Date:
Signature:
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name: SLl4
Signature:
Date: I).-(l0/94'l
FORM: LOA 06-16
Page 3 of 3

Vicinity Map
1 in = 6,000 ft
Site: NC-AM-119; Fields 1-2
A `•LA Pt.=.A N C+V
CHATHAM
Feet
0 4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
_
Town of Cary, Alamance`Co unty, State of North Carolina DOT, Esri HERE,
Garmin, INCREMENT USGS, METI%NASA, NGA, EPA, USDA
City of
URLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Budington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspect,
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Prime
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.
ry

Site: NC-AM-119; Fields 1-2
Application Area Map
1 in = 500 ft
MCCNIIMIN=EMInFeet
0 175 350 525 700
City of
URLINGTON
G.LS.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
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Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Prima
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Owner Name: STEPHENS NELDA LEE
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Site: NC-AM-119; Fields 1-2
Soil Map
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Legend
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GIS Division
Date: 1/10/2022
HaC
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URLINGTON
G.I.S.
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Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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Signature of Land Applier
DENR FORM FSF (12/2006)

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DENR FORM FSF

DWR
DMslon 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: City of Burlington
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:
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
p )
Special note
(no-till/over-seed/
pasture)
NC-AM-125-1,2,3
Yes
Row
Cron/Corn,Sovbeans
Feed
NC-AM-125-4
Yes
Fescue
Hay
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.
FORM: LOA 06-16
Page 1 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 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 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.
ILL 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;
X A re -defined compliance boundary is needed for field(s) ID: 4
(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

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 anothermunicipality, contractor,or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, altematives 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: Q�1,,�,%%
Address: 9w — ,4/% /"L
City:
Cs.xl .. State: NO Zip: 2 ?�5—,�
Phone: E-mail address:
Signature: c ` 1 c -d-- -1 Date: j ..- / a7 (zi
NORTH CAROLINA,
CO
G
I, the undersigned Notary Public do hereby certify that �©All'1(\ M Ne r s o n
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and officialsealthis the 1 U^
day of, 7)17c--P-.Z['t°0,).QC , 20 O• 1
Signature and seal: ' '
My commission expires: ' (�5''3 a
1z1
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restnc as specified herein.
¢,Lessee/operator name:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: '"--1 1\- Th , Date: !.2 I 7/v70-.1
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
hqwgie` <
Signing official name:
Signature:
Date: %��/ZC�
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-125; Fields 1-4
0
Feet
4,000 8,000
Legend
0 Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
Vicinity Map
1 in = 6,000 ft
Town of Cary, Alamo ce County State of North} Carolina DOT, Esri, HERE,
s_Garmin, INCREMENT P, USGS, METI/NASA, `NGAir,EPA, USDA
City of
BURLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primab
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-125; Fields 1-4
BCitq of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
cm Site Boundary
0 Property Line
,rElApplication Area
Unsuitable
X — Fence
V/1
❑✓ S.W.A.
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II Off Site House
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—••- Streams
Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
I
Application Area Map
1 in = 450 ft
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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GIS Division
Date: 1 /10/2022
BCity of
URLINGTON
GIS.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

D APPLICATION FIELD SUMMARY FORM
ANNUAL L
Acres Utilized:
N
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WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
N
00
Annual Dry Tons Applied:
Billy McPherson
Land Owner:
Cation Exchange Capacity (non 503):
1-4
Predominant Soil Series:
Terry McPherson
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N
3V
cn p
U CZ)
Q
O
M
N
h
N
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
South Burlington
_
(,
-
okr,
rn ©
T
��
T
oo
.MM-+
-�
(,
T
O
0
0
O
0
0
o
0
M
Volume
Applied per
Acre
(Dry Tons/Ac)
O-
o,
.-1
0
o
0
0
0
0
0.000
0
0
0
0
0
0
0.000
0
o
0
0.000
0.000
0.000
0.000
0.000
T
o
0
o
0
.r.
.�
0
M
ti
e Q
0
M
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds l Gallons
52000
o
0
o
0
0
u1izayN
JO 21EQ
F
0
E.
Signature of Land Applier
DENR FORM FSF

R
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) foiiii. 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: City of Burlington
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:
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-AM-126-1,2,3
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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
t".,\ 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
t\ 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 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)
r� ❑ 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

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 anothermunicipality, contractor,or other permitted entity. Furthermore, I certify thatlhavercad 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: ' � e \I e re, 'T fx.f vv• s 1 k c 7c S 0, 1-'„{}i''.)w-a_'',
J.
Address: 61 OD p k&.cam S u E- f lk (k C.„nv c RC
City' State: Zip: P 73 99
Phone: "el "G 1 2., E-mail address: tic,.„,. u-.,s Q Of,* lt: F ,..„,„..,
,---
Signature: (.C�n�x¢'-------
NORTH CAROLIl�A, \fit Sk m. c? COUNTY
I, the undersigned Notary Public do hereby certify that
Date: 6/7/ v2/
n* . SC) r•N c D -3 -"••••9
personally appeared before me this day and acknowledged the due execution of the forgoing instnrm ent.
WITNESS my hand and officialsealthis the
day of `1i\ C..o•` , 20 2.
Signature and seal:
SUSANMWU.LS
My commission expires: 3 i 21�JZ NOrAlr PUBUC
AIAMAN(ECOUNTY, NC
MY COMMISSION WIRES�: ?�
Lessee's/Operator's Certification:
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: E-mail address:
Signature: Date:
State:
Permittec's Certification:
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:
er—
Date:
FORM: LOA 06-16 Page 3 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: City of Burlington
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:
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-AM-126-5,6,7
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 of 3

l"\
/—N,
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 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 5,6,7
(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

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 Q1 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 anothermunicipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, altematives 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.
Landownername:
Lafr4 L F-d temar)
Address: ) ACoble . lk fwd.
City: , } In (�
Phone: 33(0-?k
Sigma
NORTH CAROi.INA,
State: ItC..
Zip:
49
E-mail address:
nce COUNTY
Date: I - 1L _ aoc e2
I, the undersigned Notary Public do hereby certify that La.(P 1 P03k) )Qr-,
personally appeared before me this day a nd acknowledged the due execution of the forgoing instrumen
WITNESS my hand and official seal this the
dayof or
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
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: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipula tions and restrictions as specified here in.
Signing officialname:
Signature:
Date: l . /`7, •2�
FORM: LOA 06-16
Page 3 of 3

D R
Division of
ter 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: City of Burlington
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:
Site/Field ID
Lease
es/no
(y )
Land Use or
Cropping Patterns
pp g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-AM-126-8
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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
/""'s 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 8
(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

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 Qa 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 anothermunicipality, 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 Penn ittee to land apply residuals to the land application site(s) as specified
herein.
Landownername: TCIW is Chad
Address: q Cg'" C.- RA.1)101 SW/oL
City: Li toe"- State: NI C_. Zip:
Phone: 33(0 - (R6c1 03 _ E-mail address: terminParrnS \fa
Signature:
NORTH CAROLINA,
an e_e_, COUNTY
I, the undersigned Notary Public do hereby certify that -Team ts Char(
Date:
1-0714- P-0a9.
personally appeared before me this day and acknowledged the due execution o f the forgoing instrument.
WITNESS my hand and official sea 1 this the +b.
day of eTankkOry
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
LAt(acay
•
I certify that I have read this Agreement and do hereby agree to a b ide by the stipulations and restrictions as specified herein.
Lessee/opera tor name:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Cerdfication:
1 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

D R
- Division
ater 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: City of Burlington
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in 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-AM-126-
9A,9B,10A,10B
Yes
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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 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 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.
IILALTERNATIVES 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:
(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)
XA re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
n ❑ 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

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 beha If 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.
La ndowner name: 1--hOCTVIS \sh Pk. e,Ai• \f
Addre„: (630(1 Plectsent U Chu,rch eci.
City: Ct\)3 COMO State: NIC__ Zip: a7340
Phone:
Signatur
NORTH CAROLINA,
E-mail address:
NM C-e _ COUNTY
Date:
1 -a oa
I, the undersigned Notary Public do hereby certify that -r-hory-)cts a %hit(
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
th
?0
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/opera tor na me: MU- QVaCt 'FOC\ rr10-n
Address: 1 QQY% Q, tb.Sal
City: LAyeAkt State: N L Zip: ac)S
phone: 33(0- 033q E-mail address: -c1/40:401 1(e)mco1-Par ()Is
Sigtature: LjDate:
Permittee's Certification:
o ..eono
1 certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name:
Signature:
Date:
FORM: LOA 06-16
Page 3 of 3

Site: NC-AM-126; Fields 1-3
Vicinity Map
1 in = 6,000 ft
ALA1ANCE
C ATHAN!
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
,N CRE
Town -of Cary, ;Alamance County, State of North Carolina DGT; Esri, HERE,
Garrmin, INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
G.I.S.
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-126; Fields 5-8
Vicinity Map
1in=6,000ft
0
Feet
4,000 8,000
rAel
LN_A
Site Location
Town of Cary, Alamance County,State of North Carolina DOT, Esri, HERE,
Garmin. INCREMENT P, USGS, METI/NASA, I GA, EPA, USDA
Legend
® Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/25/2022
BCity of
URLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale. time, origin. definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-126; Fields 9-10
Vicinity Map
1in=6,000ft
0
ALA MAN GE
CHA1HAM
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
Town of Cary;'Alamance County State of North Carolina DOT, Esri, HERE,
-Garmin;INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
BCity of
URLINGTON
G.I.S.thk
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map Neither the City of Bud ngton nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required. must be consulted
for the verification of the information contained within this map.

ite: NC-AM-126; Fields 1-3
Application Area Map
city of
fItURLINGTON,
G.I.S.
GIS Division
Date: 1 /11 /2022
`Note: Acreage calculated in GIS
Legend
=Site Boundary
= Property Line
lApplication Area
Unsuitable
X — Fence
V/1
S.W.A.
® On Site House
III Off Site House
(-1 Outbuildings
On Site Well
-0- Off Site Well
--- Streams Disclaimer
— Drains This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
Surface Water
different scale, time, origin, definition and accuracy, which aspects
Flood Zones' produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
AE be held liable for any errors in this map or supporting data. Primary
Floodway (AE) public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
0.2% Annual Chance Flood Hazard for the verification of the information contained within this map.
I 1

Site: NC-AM-126: Fields 5-8
City of
URLINGTON.-y
G.I.S.
GIS Division
Date: 1/25/2022
`Note: Acreage calculated in GIS
Legend
Q Site Boundary
Q Property Line
1 4 l Application Area
Unsuitable
V/I
X — Fence
S.W.A.
On Site House
II Off Site House
Outbuildings
On Site Well
-0- Off Site Well
• Streams
Drains
L� Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Application Area Map
1 in = 600 ft
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time. origin. definition and accuracy. which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled. in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-126; Fields 9-10
Application Area Map
1 in = 600 ft
C ty of
UR_ LINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
Site Boundary
Property Line
1'd
Application Area
1771 Unsuitable
X — Fence
• S.W.A.
II On Site House
▪ Off Site House
Outbuildings
On Site Well
-0- Off Site Well
— — Streams
— Drains
Surface Water
Flood Zones:
AE
'/ Floodway (AE)
0.2% Annual Chance Flood Hazard
Disclaimer.
This map was compiled from the GIS resources of the Budington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must he consulted
for the verification of the information contained within this map.

Owner Name: B SEVEN FARMS LLC
cy)
0
0
0
I
Parcels New ID
5 Ft Contours

Owner Name: B SEVEN FARMS LLC
wc,
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Site: NC-AM-126; Fields 1-3
Soil Map
1 in = 1.000 ft
Feet
750 1,500
Legend
0 Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
Casty of
BURLINGTON,
-1
...a? G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-AM-126; Fields 5-8
Soil Map
i in = 1,000 ft
Fee
750 1,500
Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1/25/2022
VV
CeB2
VaC
VaB VaC
City of
URLINGTON,
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scald lime, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in Ibis map or suppor1ng data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required. must be consulted
for the verification of the information contained within this map.

Site: NC-AM-126; Fields 9-10
Soil Map
1 in - 1 nnn 4
Legend
Q Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Budington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

00
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
00
Acres Permitted:
00
Annual Dry Tons Applied:
Larry Fogleman
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Larry Fogleman
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Nitrate
TKN and
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mg/kg mg/kg mg/kg
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Signature of Land Applier
DENR FORM FSF

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
rl
N
Annual Dry Tons Applied:
as
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Land Owner:
Cation Exchange Capacity (non 503):
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Larry Fogleman
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DENR FORM FSF

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
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DENR FORM FSF

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NC-AM-00126-0-0004
NC-AM-00126-0-0005-
NC-AM-00126-0-0006-
NC-AM-00126-0-0007-
NC-AM-00126-0-0008-
11 /15/2012
N C-AM-00126-0-0009-
NC-AM-00126-0-0010-
Report Date/Time: 1/25/2022 3:23:37 PM

DWR
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 Perm Jn,t
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 1 SA 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.
EL 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: City of Burlington
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:
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-CS-18-1
Yes
Fescue
Hay/Pasture
> ne 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.
FORM: LOA 06-16
Page 1 of 3

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, I5A 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:
(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)
X 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;
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.
IL 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 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.
(Name of the new program)
FORM: LOA 06-16
Page 2 of 3

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: Delm et' A' ct
Address: G"' O1= �n` S..i /4 Z L, Reb Rb i- r
City: Z State: N �.. Zip: . I' 2 7'
Phone: 33 b 4.1— 3748 E-mail address:
-Signature: Q ,�/�,i ' taste JZ, Q Date:
NORTH CAROLINA, CA S 1.4)G L L• COUNTY
I, the undersigned Notary Public do hereby certify that
-7,inna,C vJ . Ad
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
day of (?('
.
and seal: C i'�ua"iaV+ Q,Q. 141) . Olabbay
My commission expires:
Signature
Lessee's/Operator's Certification:
,20 RI
yy�
I certify that I have read this Agreement and do hereby agree to abide by the stipulations a . - rictions as specified herein.
.Lessee/operatorrname: je'i.' is J,;11 0145
Address: 28 20 »,1L+9s`%/L.L e A7).
City: e'%,D ( State: /Y. C.
Zip: rG 12 4L4--
Phone: 13 "',2109 %D 1 .E-mail address:
Signature:
Permittee's Certification:
Date: 4 -27- 21
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
S rick.
Signing officialname:
Signature:
Date:
/oL//S/,ot'/
FORM: LOA 06-16
Page 3 of 3

Site: NC-CS-018; Field 1
Vicinity Map
1 in = 6,000 ft
N
State of North Carolina DOT, Esri,, HERE, Garmin, INCREMENT P, USGS,
Feet
0 4,000 8,000
METI/NASA, NGA,EPA, USDA
Legend
0 Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/10/2022
City of
URLINGTON��
G.I.S. �XJ
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CS-018; Field 1
Fee
175 350 525 700
City of
URLINGTON,-
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
=Site Boundary
= Property Line
Application Area
Unsuitable
X — Fence
V/1
▪ S.W.A.
On Site House
▪ Off Site House
[ j Outbuildings
On Site Well
-0- Off Site Well
— — Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
I
Application Area Map
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CS-18
(all locations approximate)
1 inch = 1,000 feet

Site: NC-CS-018; Field 1
Soil Map
Exc EnB
ExC
xC
FgB
EnB
ChA
'ExC CuB2
CuC2.
FgB-
CuD2
EnC
EnC
ExD
EnB
0
EnB
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1%03
- -EnD
Feet
750 1,500
ExD
Ena
fffaD
1%0
14113
EnB
FgC
EnB
Legend
=I Approved Application Fields
0 Field Numbers
GIS Division
Date: 1/10/2022
City of
URLINGTON
G.I.S.
FgC
FgC
FgC
FgB
= 1,UUU T1
FgC
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Buffington nor the Partnership shall
be held liable for any en -ors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Acres Utilized:
71*
00
Acres Permitted:
00
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WQ Permit #:
City of Burlington
Facility Name:
Annual Dry Tons Applied:
Delmar Allred
Land Owner:
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Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
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 1 5A 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: City of Burlington
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:
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-C
6,7,8,9,1010,11,12
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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 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 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.
IILALTERNATIVES 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;
X A re -defined compliance boundary is needed for field(s) ID: 6,8,9,10,11
(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

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 Agr eement,
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: eHi is .S244 A4014 S
Address: ,2 $2 ® %7 I LEES ab
City: EZO4 State: Al C.
Zip: d272 47"'
Phone:.3 "`dFtS' 176 ( E-mail address:
Signature: ,�►'i2/Y:4�+ 1i .
Date:
,S /-2021
NORTH CAROLINA COUNTY
I, the undersigned Notary Public do hereby certify that Z) QAtl t 9 Cj t tY1C/1 en S
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the
day of , 20 a L
Signature and seal: •
My commission expires: ?f°,
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions . .. - led herein.
Lessee/operator name:
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
I certify thatI have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name: S E/! a —a_ Fte.t-c,L.
Signature: Date: /t.l3 7D Zi
FORM: LOA 06-16
Page 3 of 3

Site: NC-CS-036; Fields 6-12
Vicinity Map
1 in = 6,000 ft
0
Feet
4,000 8,000
ALA MA NC
State of North Carolina DOT, Esri HERE, Garmin,1NCREMENT P, USGS,
METI%NASA, NGA, EPA, USDA
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
City of
URLINGTON
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CS-036; Fields 6-12
Application Area Map
tin=600ft
Feet
210 420 630 840
RCity of
URLINGTONd
11'' G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend ® S.W.A.
QSite Boundary ® On Site House
0 Property Line Off Site House
Application Area MOutbuildings
1771 Unsuitable \ On Site Well
X — Fence -0- Off Site Well
— - Streams
Drains
Surface Water
Flood Zones:
AE
,0 Floodway (AE)
0.2% Annual Chance Flood Hazard
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CS-036; Fields 6-12
Application Area Map
1 in = 450 ft
City of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
Site Boundary
0 Property Line
,Application Area
V71 Unsuitable
X — Fence
▪ S.W.A.
® On Site House
▪ Off Site House
Outbuildings
On Site Well
-0- Off Site Well
--- Streams
— Drains
I I
Surface Water
Flood Zones:
AE
/ Floodway (AE)
0.2% Annual Chance Flood Hazard
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CS-36 (Simmons)
Topographic Map
(all locations approximate)
1 inch = 1,000 feet

Site: NC-CS-036; Fields 6-12
Soil Map
1 in = 1,000 ft
Legend
Q Approved Application Fields
0 Field Numbers
GIS Division
Date: 1/10/2022
City of
URLINGTON
w 9
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Acres Utilized:
0
0
CY
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
M
C/1
u
0
Annual Dry Tons Applied:
Land Owner:
O
Cation Exchange Capacity (non 503):
Predominant Soil Series:
CA
v
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as
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00
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0
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Name of Crop Type
Receiving Residual
Application
Crop 2
N
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w
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PAN Applied
( lbs/acre)
a,
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Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
p„,
o
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00
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0
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M
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Rate**
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(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington
"C
N
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1 0.587J
cn
Volume
Applied per
Acre
(Dry Tons/Ac)
,,
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M
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Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R. * * * *
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
123500
214500
26000
©
364000
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Signature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
Acres Permitted:
m
L)
.9 4.1
N
0(1
WQ Permit #:
City of Burlington
Facility Name:
N
"71-
Annual Dry Tons Applied:
rn
0
•
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
0
O
i
94
iOn
E
z
0
00
00
0
Fescue -Pasture
Name of Crop Type
Receiving Residual
Application
Crop 2 I
Lime Applied
lbs/ac
p+
°
C.)
U
w
U
0
w
Y
A
PAN Applied
( lbs/acre)
N
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O
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U
Q
Z
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0
O
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0
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O
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0
0
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0
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0
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0
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Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
a
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Ammonia m
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o
o
0
N
m
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0
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20.267
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
U71-
Ln
O
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o
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,n
'Q
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0
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m
M
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m
m
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
221000
130000 1
0
3510001
0
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Signature of Land Applier
DENR FORM FSF

00
00
0
Acres Utilized:
00
N
CY
WQ Permit #:
City of Burlington
Facility Name:
00
00
Acres Permitted:
Annual Dry Tons Applied:
0
v1
0)
N
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
0
00
0
7r
041
0
0
U
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z
N
0
0
00
00
a,
0
0
GO
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U
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z
0
0
Name of Crop Type,
Receiving Residual
Application
Crop 2 1
I Lime Applied
Q
Cd
Z
1-0
88
0
Q
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U
www
U
U
PAN Applied
( lbs/acre)
N
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0
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0
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0
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0
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0
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0
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0
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z 0Z E
Mrn
I- I Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
a
v
,
N
g
NCr,
o
N
,-+N
00
Ammonia -°'
tT
Nitrogen E
0
O
'o
0
O
'0
0
O
�
00
O
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M-
O
00
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cr.,
op
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O
0
ci
O
0
cl
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0
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z
o
o
00
M
,
m
Mineralizatio
n Rate***
m
0
r
0
o
0
o
0
N
N
Volatilization
Rate**
v,
o
zn
0
V,
0
a
x
o
o
0
0
0Method*
Application
,SZ.{
co
N
O
CA
00
N
N
00
N
A. 7' G
U N N • L
tom. P. a .'ri C
1
V
V,
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c�oo'o
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q
AcaQ
62GO
7`
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington I
East Burlington
":i
U
00
N
O
000
—
0
Y1
C
00
z)
d
M
Volume
Applied per
Acre
(Dry Tons/Ac)
0
r.
1.387
0.335
0.000
0.000
0.000
0.000
0
0
O
0
0
0
0.000
0
0
O
0
0
0
0.000
G
0.0 88
r-
0
0.498
w
r.,
o o
un
Annuallbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit 1 st/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
58500
78000
26000
I 162500
O
uoy�
JOMG
00
N
00
M
00
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0
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N
N
U
0
Signature of Land Applier
DENR FORM FSF

D APPLICATION FIELD SUMMARY FORM
ANNUAL L
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
a1
0
CY
WQ Permit #:
City of Burlington
Facility Name:
Acres Permitted:
V,
0
N
Annual Dry Tons Applied:
a)
Land Owner:
O
Cation Exchange Capacity (non 503):
Predominant Soil Series:
en
a)
Q
5
z
a
ai
0
U
N
E
z
Name of Crop Type
Receiving Residual
Application
Crop 2 I
Lime Applied 1
U
Ct
0
En
PAN Applied
( lbs/acre)
N
0.
o
�j
.a
z
O
0
o
0
0
0
0
0
O
0
00
C
O
0
0
O
0
0
0
O
0
0
0
0
0
00
0
O
0
0
O
0
0
0
O
0
0
co
O
0
0
0
0
0
0
0
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0
0
0
—
a
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""
o.
0
cj
�
m
46
o
06
0
o
0
0
0
0
0
0
0
0
0
0
0
©
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
o
0
N-
4
cC "0 Y
z °z E
M
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
O
Ammonia Y
CD
Nitrogen E
O
o
r
N
=
"'"
N
oN
Le-,N
00
0)
W Y
F- E
O
co
N
i�
o
O
N
O
N
O
00
Mineralizatio
n Rate***
t.,
0
Z
rn
O
O
c",
N
7
N
v
rr-
Volatilization
Rate**
Le,
0
0
—
o
o
No
,..
0
—
Application
Method*
CA
a..
^
o
o
0
0
'ci) Vyi2c
�x
a
a
N
64Na
M
,o
t`
v
Cr
12.104
13.906
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington 1
U
CT
ckc
0
0
M
4
M
NI
M
r,
-
U
N
O
O
N
O
0
M
O
M
Volume
Applied per
Acre
(Dry Tons/Ac)
M
I--
cV
0.000
0
0
0
O
0.000
0.000
000'0
0.000
0.000
0
0
O
O
0
0
O
O
0.000
0
0
O
O
0
0
O
0
As
N
N
O
0
0
N
0
CO
N
N
O
en
'O
o
Id
io
M
M
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
149500
co,
I 149500
0
O
uluoW
.to MaN
co
ty
o
Signature of Land Applier
DENR FORM FSF

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
Acres Permitted:
xi
wcA
0
N
O
O
0
WQ Permit #:
City of Burlington
Facility Name:
Annual Dry Tons Applied:
0
V1
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
0
Sr
6)
V
E
z
00
00
A
O
U
Fescue -Pasture
z
O
Name of Crop Type
Receiving Residual
Application
Crop 2 I
Lime Applied I
o
as
z
.n
N
A
O
$-,
U
rVi,
N
4-1
N
w
PAN Applied
( lbs/acre)
{1
S3�
0
Q�
z
Q
Z
0
O
0
O
0
O
O
O
0
o
O
O
0
0
0
O
0
0
O
O
0
0
O
O
0
0
O
O
0
0
O
O
0
0
O
O
0
0
O
O
0
00
O
O
0
O
O
—
op
00
¢,
Q
U
tO
N
N
.
N
O
0
O
O
0
0
O
O
O
0
O
O
O
0
O
O
O
0
0
O
co
0
0
O
O
0
0
O
co
0
0
O
co
0
0
O
O
0
0
O
co
0
0
O
0
0
z °z E
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
''o
rn
occ
o
7rcv--
rn
�
Ammonia
Nitrogen E
o
oo
o
E" E
0
O
N
O
0cn
N
U
o0
N
O
O
v
OA
M
O
M
N
O
p,
00
Mineralizatio
n Rate***
t-,
0
M
0
Z
o_
o
on
N
N
K
Volatilization
Rate**
v,
0
v,
'
0
N
o
o
0
ci
-.
N
--
°A
`�
o
0
0
0
0
0
"'
Application
cil
c/aMethod*
p
00
N
o
o
t�
v3
4
V1
co
co
v
[�
N
N
U N •ti N
c`cl x c
0-1 a
_
-
V
_
V
o
.
r-.
Q
v
A
aa
A
O
00
M
M
Residual Sources
(NPDES #, WQ#,
Pert., Animal
Waste, etc)
East Burlington
East Burlington 1
'G
00
N
O
O
k
0\
N
O
M
N
M
O
M
Volume
Applied per
Acre
(Dry Tons/Ac)
1.430
cn
V1
M
0.000
0.000
0.000
0
0
0
0
0.000
0.000
0.000
0
o
o
0
0
0
0
0
0
0
0
0
o
0
0
0
ell
I 0.028
t-
M
M
0
v)
b
M
0
,p
M
m
to
M
M
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds Gallons
123500
117000
0
I 2405001
O
0
tPUOI
JO MU
N
o
N
0
0
Signature of Land Applie
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
0
00
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name:
09
Acres Permitted:
L)
Annual Dry Tons Applied:
•
Q
Land Owner:
0
Cation Exchange Capacity (non 503):
Predominant Soil Series:
tip
C
N
A
R
0
00
00
00
0)
U
A)
G
00
z
w
Name of Crop Type
Receiving Residual
Application
Crop 2 I
I Lime Applied
U
O
cn
Q
U
U
w
0O 0
w
PAN Applied
( lbs/acre)
N
o
j
d
z
Q
z
o
o
o
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
o
0
0
0
O
0
0
0
o
0
0
0
o
0
0
0
O
0
00
0
o
0
0
0
0
0
0
co
00
O
M
N
M
N
en
O
0
0
0
0
0
0
0
0
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
0
0
O
0
CC
0
O
0
0
O
0
O
0
l0
y y
o
o
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
0
o
Ammonia °
Nitrogen E
o
o
o
`''
c
oO,
,i
PO
M
o
rn
N
,:n
F'" E
a
M
o
M
o
o
C
0
N
0
o0o
Mineralizatio
n Rate***
en
0
M
0
�%
N
c
©
0000
-
o
cc
m
Volatilization
Rate**
in
kr)
o
o
c
o
„-,
0
0
Application
Method*
x
©
o
0
o
0
O
-
4 U
a a x c
V
V
0.1
c)
O
on
N
c..-)
N
N
ili
.O 'z y
col c5Q
>,
L
�,
A
Cr
N
o,:
t
o
Residual Sources
(NPDES #, WQ#,
Fert., Animal
Waste, etc)
East Burlington
East Burlington
en
oo
O
0
a`
en
00
U
V1
O
O
00
N
O
M
N
o
cv.71-
j
Volume
Applied per
Acre
(Dry Tons/Ac)
O
M
—
0.000
O
o
O
0
O
0
0.000
0.000
0
0
0
0
0.000
0.000 I
0.025
0.258
0.283
36
i
o
VD
CrN
01
M
CA
T
M
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
117000
0
O
I 2665001
0
0
quoIN
zo maO
N
o
N
enH
C7
H
c
0.0
00
00
v
E
E
00
0
4.N
GA
i:.
0)
0
75
v
C
f0
00
g
w
•a
O
c
O
c R
0
• O
O
o
d
z—
do
c.>
t •
O �
• Lt
O
.c
O
O
O
R
U 'r
• SOa
Q
* *
N
N
N
Signature of Land Applier
DENR FORM FSF (12/2006)

D APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
O
CY
WQ Permit #:
City of Burlington
Facility Name:
M
N
Acres Permitted:
Annual Dry Tons Applied:
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
0
O
d)
O
z
N
00
Fescue -Pasture
z
U
Name of Crop Type
Receiving Residual
Application
L_ _ Crop 2 I
Lime Applied
v
ct
n
4,
,-e
O
U
9)
0
9)
w
9)
7
9)
W.
0
9)
w
PAN Applied
(lbs/acre)
N
U
.
z
Q
z
Q
z
C.
0
0
o
0
0
0
0
0
0
00
0
0
0
0
0
0
0
0
0
0
C.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
pp
pp
--,
G.
0
U
O
O
O
O
N
00
N�
O
0
O
O
O
0
O
O
O
00
C.
O
O
O
O
o
0
0
C.
0
0
C.
C.
0
0
O
O
0
0
0
O
0
0
0•
O
0
0
0
O
.--,
,40
z�z E
ications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
Ammonia
Nitrogen E
o
r-
o
o
N
cri
v
o
v
00
NNv
Y0
o
0
C.
M
O
0
C.
M
O
0
0
M
y
N
0
O
Ccr,T,
N
0
NN
M
0
q�
co
Mineralizatio
n Rate***
M
O
en
o
enN
o
Z
en
o
0
cn
0,
,-.
00
CT
,-
r
M
Volatilization
Rate**
,n
,n
0
,n
0
O
cM
O
0
N
0o
0
A
00
0
Application
Method*
VDo
O
0
O
0
C.
0
C) N 4 • L
2 Z" c
,n
V.
Vl
V
L l
V
..O
py
N
O o
V3
e;
M
oo
cn
M
N
N
ri U
A
A
G
A
Cr
o
6.704
Residual Sources
(NPDES #, WQ#,
Pert., Animal
Waste, etc)
East Burlington
East Burlington
0
.
Residuals Appl
00
O
M
N
N
Z.)
O
0
N
O
N
O
0-)W
Volume
Applied per
Acre
(Dry Tons(Ac)
0.394
0.394
-,
vl
,--i
O
O
0
O
0
0
0.000
0.000
0.000
0
O
O
0
0
O
0.000
0.000
O
O
O
As
M
O
O
0.279
N
0
M
O
M
kA
7
0 0
�
M
CA
Q
M
01
M
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit l st/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
58500
0
C.
,n
00
,n
227500
0
344500
0
0
tpuow
zo aleQ
N
0
N
efi
Q
F"
0
Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
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. L nd 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.
PPrepare 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: City of Burlington
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:
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-CH-39-1,2,3,4
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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.
IL 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 1,4
(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)
/'1 ❑ 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)
Page 2 of 3
FORM: LOA 06-16

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, altematives 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:
/ S'G / Rw4ts 13r _ r2---�-
Address:
City: l .- ei i/ State: /t14- Zip: al 3
Phone: 3 340- 6, f ' 4? p '2"` E-mail address:
��/4- gAs.. - Date: / Z/ /a /. O Z'i
Signature: ®�(�
NORTH CAROLINA,�.�' 'aIVCOUNTY
I, the undersigned Notary Public do hereby certify that \o.ime.S 1. , rew
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the 1
day of CaQ,
--� N\ n
Signature and seal: Qp(( _Xn, •"f�i!�iL4
My commission expires: CT " O ' O� a
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulatio }-�- .T as specified herein.
,20 at
lessee/operator name:
Address:
City: State: Zip:
Phone:
Date:
Signature:
E-mail address:
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name:
Date: lZ7//r
Z4
Signature:
FORM: LOA 06-16
Page 3 of 3

Site: NC-CH-039; Fields 1-4
Feet
10 4,000 8,000
Legend
Q Subject Farm Boundary
---- Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
Vicinity Map
1 in = 6,000 ft
Town of Cary, State of North Carolina DOT, Esri, HERE, Garmin,
INCREMENT P, USGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
...'� ; - G.I. ►.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspect,
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CH-039; Fields 1-4
Application Area Map
1 in = 660 ft
Feet
0 230 460 690 920
City of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
© Site Boundary
= Property Line
Application Area
Unsuitable
X — Fence
V/1
S.W.A.
�� J On Site House
Off Site House
Li Outbuildings
On Site Well
-0- Off Site Well
---- Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Prima
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CH-39
(all locations approximate)
Topographic
ap
1 inch = 1,000 feet

Site: NC-CH-039; Fields 1-4
Soil Map
1 in = 1,000 ft
750
1,500
Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1 /10/2022
BCity of
URLINGTON
{ G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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DENR FORM FSF

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DENR FORM FSF

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Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
1 SA 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):
ck 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
le_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: City of Burlington
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:
Site/Field ID
Lease
es/no
(yes/no)
Land Use or
Cropping Patterns
pp g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-CH-40-1
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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.
IL 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 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.
IILALTERNATIVES 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, I5A 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;
X A re -defined compliance boundary is needed for field(s) ID: 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 program;
(Name of the new program)
FORM: LOA 06-16
Page 2 of 3

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 anothermunicipality, 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: Or 1 vN /?/Gu A•
Address: ,.779
City: S' /e t.- Ct
Phone:
Signature:
State: A/ c Zip: a 7 Si
E-mail address:
Date:
NORTH CAROLINA, kak44...,y) COUNTY
I, the undersigned Notary Public do hereby certify that 79f L CU1 Cbreilkper
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the ‘04Ch
day of )0,P Q�"t1,p , 20 RI
Signature and seal: .N .Q. . fi
My commission expires:
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations an. . i , pecified herein.
Lessee/operatorname: 011411r btJG1
Address: /5-72/ .K, Cr@Ul
City: �. l Qili � State: N f/ Zip: 9'13 YY
Phone: `, 36,- 627- (P2--
E-mail address:
Signature:
Permittee's Certification:
Date: / %—/f
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name:
Signature:
Date: /Zl(VW) 1-/
FORM: LOA 06-16
Page 3 of 3

DWR
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: City of Burlington
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:
Site/Field ID
(yes/no)
Land Use or
Cropping Patterns
Intended
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-CH-40-1
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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 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 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.
IILALTERNATIVES 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;
X A re -defined compliance boundary is needed for field(s) ID: 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 program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

I certify that I am a deeded landowner of the above -referenced land application sites) 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: `I;ffYlif 3(e1,ver
Address: /*!r
City: Si am- G State: A/C -
Phone: 3 ' 6,1 /- E-mail address:
Signature: gnu"
Date:
Zip:
NORTH AROLINA, NO.:01—Vi t."1 COUNTY
I, the undersigned Notary Public do hereby certify that JalV%LS 1J reAJJe 1'
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the 10 t N
day of Q¢_c.e. ,bQ( .20 a
Signature and seal:
My commission expires: `� -oZ A
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulatio �, .t":. 'T as specified herein.
Lessee/opera tor name:
Address:
City: State:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
a
Signing official name:
Signature:
Date:
FORM: LOA 06-16
Page3of3

Site: NC-CH-040; Field 1
Vicinity Map
1 in = 6,000 ft
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
r41
Town of Cary, State of NorttCarolina DOT, Esri, HERE, Garmin,
INCREMENT R; USGS, METI/NASA, NGA, EPA, USDA
City of
URLINGTON
G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CH-040; Field 1
BCity of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
=Site Boundary
= Property Line
Application Area
Unsuitable
X — Fence
V/1
• S.W.A.
kJ On Site House
▪ Off Site House
Outbuildings
On Site Well
-0- Off Site Well
Application Area Map
tin=450ft
--i3i- Streams
— Drains
Surface Water
Flood Zones:
AE
# I Floodway (AE)
0.2% Annual Chance Flood Hazard
I 1
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site:NC-CH-40
(all locations approximate)
1 inch = 1,000 feet

Site: NC-CH-040; Field 1
Legend
Q Approved Application Fields
OField Numbers
GIS Division
Date: 1 /10/2022
City of
URLINGTON
Soil Map
tin=1,000ft
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL L
PLEASE MAKE A COPY OF THIS BL
Acres Utilized:
WQ Permit #:
City of Burlington
Facility Name
Acres Permitted:
co
co
Annual Dry Tons Applied:
James Brewer
Land Owner:
0
Cation Exchange Capacity (non 503):
C7
Predominant Soil Series:
James Brewer
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Fescue -Pasture
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z
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Name of Crop Type
Receiving Residual
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Crop 2
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ications totals on FORM FSF supp ( attach FORM FSF supp to this form):
0
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Ammonia to)o
Nitrogen E'I"
0
0
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Residual Sources
(NPDES #, WQ#,
Fen., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington
East Burlington
Residuals Appl
U6
o
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N
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N
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Volume
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(Dry Tons/Ac)
N
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Annual lbs/acre 1
Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R.****
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds Gallons
52000
156000
104000
149500
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re of Land Applier
DENR FORM FSF (12/2006)

DWR
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.
la Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
It 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: City of Burlington
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:
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-CH-98-
1,2,3,4,5,6,7,8,9,10
Yes
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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 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-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.
HLALTERNATIVES 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;
X A re -defined compliance boundary is needed for field(s) ID: 1,2
(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

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: 'l1//4/17 C/0di&•vk
Address:
City:
Phone:
Signature:
A / / i c 12,1.
air,/
?79'-Yo
E-mail address:
State: r`^ // Zip: 2j 7 Z of J
h.Pf-0;O/( a.h (� a '!
Date: C
NORTH CAROLINA l 9i.+ t Y COUNTY
C00-1
I, the undersigned Notary Public do hereby certify that ` 1 it t) c Wd (A. N VC if 6 0/6 7:
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sea lthis the
day of
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
I certify that I have read this A
Lessee/operator name:
Address:
City:
/Phone:
v`Signature:
` ,20
1 1rtC� C L rlvwi�
oaq-
SHERESE L THOMAS
Notary Public
Guilford Co., North Carolina.
My Commission Expires Oct. "23, 2024
eement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Permittee's Certification:
State: Zip:
E-mail address:
Date: 6-, /3/ 1
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name:
Signature:
Date: if /3/'20
FORM: LOA 06-16 Page 3 of 3

Site: NC-CH-098; Fields 1-10
Vicinity Map
1 in = 6,000 ft
0
Feet
4,000 8,000
Legend
Q Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1/10/2022
'72 Y
Town ibf Cary, State of North Carolina DOT,Esri, HERE, Garmin,
INCREMENT P, USGS, METI/NASA, NGA,%EPA, USDA
BCity of
UR/L�INGTONG.I.S.
.I.S.'
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CH-098; Fields 1-10
BURL'
Cityuf Legend
NGTON Site Boundary
G.I.S. Q Property Line
GIS Division
Application Area
Date: 1/11/2022 Unsuitable
*Note: Acreage calculated in GIS X — Fence
1' d
▪ S.W.A.
® On Site House
▪ Off Site House
Outbuildings
On Site Well
-0- Off Site Well
— • Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
1 I
Application Area Map
1 in = 600 ft
Disclaimer
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CH-098; Fields 1 -10
Application Area Map
1 in = 600 ft
City of
URLINGTON
G.I.S.
GIS Division
Date: 1 /11 /2022
•Note: Acreage calculated in GIS
Legend
QSite Boundary
0 Property Line
Application Area
Unsuitable
X — Fence
V4J
• S.W.A.
® On Site House
El Off Site House
Outbuildings
On Site Well
-0- Off Site Well
• Streams
• — Drains
I I Surface Water
Flood Zones:
AE
FA0V4, Floodway (AE)
0.2% Annual Chance Flood Hazard
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held viable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CH-98
(all locations approximate)
Topographic
ap
1 inch = 1,000 feet

Site: NC-CH-098; Fields 1-10
Soil Map
1 in = 1,000 ft
CnD2 HrB2 IaC
HrB2
CnB2 HrC2
HnB
F9 rB2'�-
Legend
0 Approved Application Fields
0 Field Numbers
GIS Division
Date: 1/10/2022
City of
URLINGTON
G.I.S..
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
COPY OF THIS BLANK FO
PLEASE M
EN NOT APPLICABLE.
0000
Acres Utilized:
City of Burlington
Facility Name:
0000
Acres Permitted:
d;
00
Annual Dry Tons Applied:
William Brookba
Land Owner:
Cation Exchange Capacity (non 503):
b
Ca
Predominant Soil Series:
Bobby Cooper
F
CC
z
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00
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Fescue -Pasture
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Name of Crop Type
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Crop 2 I
Lime Applied
0
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Fert., Animal
Waste, etc)
East Burlington
East Burlington
East Burlington)
0
u
0
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M
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Volume applied
(enter one) Solids/
Liquid
Cu. Yds Gallons
26000
26000
26000
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ignature of Land Applier
DENR FORM FSF (12/2006)

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
00
r.,
Acres Utilized:
M
WQ Permit #:
y of Burlington
U
Facility Name:
00
Acres Permitted:
00
ce
Annual Dry Tons Applied:
William Brookbank Jr
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Cation Exchange Capaci
Predominant Soil Series:
0
0
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N
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0
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0
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0
0
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0
0
0
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0
0
0
O
0
0
0
00
00
0
0
0
0
O
0
N
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ZZ. E
N
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
o
N
Ammonia
Nitrogen E
O
0
g
N
m
o
m
m
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0
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Volatilization
Rate**
O
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0
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0
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N
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(NPDES #, WQ#,
Fert., Animal
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East Burlington
P
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00
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00
m
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00
m
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U
O
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0
000
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0
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0
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Volume
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Acre
(Dry Tons/Ac)
00
a\
0
o
0
0
0
0
0
0.000
0.000
0
0
0
0.000 J
0.000
0.000
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0
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0
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Current Cumulative lbs/ac
Permitted C. P. L. R.****
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Liquid
Cu. Yds I Gallons
32500
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re of Land Applier
DENR FORM FSF (12/2006

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
EN NOT APPLICABLE.
PLACE A "N/A" IN A BLANK OR BOX
krs
N
Acres Utilized:
N
CY
WQ Permit #:
City of Burlington
Facility Name:
trs
N
Acres Permitted:
0
Annual Dry Tons Applied:
William Brookba
Land Owner:
0
Cation Exchange Capacity (non 503):
Predominant Soil Series:
Bobby Cooper
06
5
z
U
Name of Crop Type
Receiving Residual
Application
N
o
Lime Applied
0
O.
O
U
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w
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(lbs/acre)
N
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ications totals on FORM FSF supp ( attach FORM FSF supp to this form):
Ammonia
Nitrogen E
o
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00
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v
N
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O
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Fert., Animal
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East Burlington
Residuals Appl
U
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O
N
inn
m
00
M
U
O
O
O
O
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Volume
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0.074
0.000
0.000
0.000
0.000
0.000
0.000
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N
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Prior Years Cumulative lbs/ac
Current Cumulative lbs/ac
Permitted C. P. L. R. * * * *
Permit PAN Limit lst/2nd Crop
Volume applied
(enter one) Solids/
Liquid
Cu. Yds I Gallons
13000
0
13000
0
o'
cV
N
Signature of Land App
DENR FORM FSF (12/2006

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Acres Utilized:
cc
CY
WQ Permit #:
City of Burlington
Facility Name:
crs
Acres Permitted:
6.0
Annual Dry Tons Applied:
William Brookbank Jr.
Land Owner:
Cation Exchange Capacity (non 503):
Predominant Soil Series:
v
0
0
0
0
as
v
c
00
ai
N
00
z
c.
U
Name of Crop Type
Receiving Residual
Application
Crop 2
Lime Applied
lbs/ac I
0
U
0
w
PAN Applied
( lbs/acre)
N
fa...,
o
ej
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0
O
o
o
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
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0
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0
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cts m
Z z E
ications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
c
N
Ammonia Y
N
0
-
v,
N
.
°;
rn
N
Nitrogen E
rn
o
0
N
O
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0
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O
0
MM
O
0,O
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Mineralizatio
n Rate***
Oen
Z
o
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0
o
N
Volatilization
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v,
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0
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0
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N
O
O
M
0
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551.0
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Fert., Animal
Waste, etc)
East Burlington
Residuals Appl
d-
camp
0
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0
0
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Volume applied
(enter one) Solids/
Liquid
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104000
104000
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Signature of Land Applier
DENR FORM FSF

TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLEASE MAKE A COPY OF THIS BLANK FO
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
oc
00
00
Acres Utilized:
0
kn
WQ Permit #:
City of Burlington
Facility Name:
r-
00
00
Acres Permitted:
00
U
N
cat
Annual Dry Tons Applied:
William Brookbank
Land Owner:
Cation Exchange Capacity (non 503):
E
Predominant Soil Series:
Bobby Cooper
P•
0
5
z
N
O
0
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77
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Signature of Land Applier
DENR FORM FSF

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
EN NOT APPLICABLE.
PLACE A "N/A" IN A BLANK OR BOX
0
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DENR FORM FSF (12/2006)

PLEASE MAKE A COPY 0
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5
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Signature of Land Appli
DENR FORM FSF

EN NOT APPLICABLE.
PLACE A "N/A" IN A BLANK OR BOX
cI
N
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Cr,
WQ Permit #:
City of Burlington
N
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ications totals on FORM FSF supp ( attach FORM FSF supp to this form): 1
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Signature of Land Applier
DENR FORM FSF (12/2006)

z
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EN NOT APPLICABLE.
Acres Utilized:
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Facility Name:
Acres Permitted:
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William Brookbank Jr.
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0
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ala
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Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form): I
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East Burlington
East Burlington
East Burlington
cn
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1.280
0.739
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104000
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Signature of Land Applier
DENR FORM FSF (12/2006)

DWR
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: City of Burlington
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:
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-CH-251-1
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 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 program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

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. 1 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 Ihave 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. r�i
Landowner name: 0,24S ( Y1.D-r(`aS S . "�'�' ✓�e.+�L
Address: 2 a--`3 I.- d— () 1--a
City: Pt 4i2ei J State: Ai Zip: --)1 3 12
GG
Phone: "1\ g54a71.1f E-mail addfess:
Signature: l Lai* j. c aad-1
NORTH CAROLINA, C La440441. COUNTY
Date: I — /0 ` ...1Da- a_
I, the undersigned Notary Public do hereby certify that Stetar2 4 fi G}AkitLY (initials: ir ) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence Chet.fi“ 5 (44-wtoh, signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS m
y hand and ..-�, off ialsealthis the j 3 day of 'exteiva+t% , 20 Z Z
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
NOTARY PUBLIC _
GUILFORD COUNTv
STATE Or (j . L. •; •.INA
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: State: Zip:
Phone: E-mail address:
Signature: Date:
Permittee's Certification:
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: S C14+^a--
Signature:
Date: /0/5,-y
FORM: LOA 06-16
Page 3 of 3

DWR
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: City of Burlington
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:
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-CH-251-2
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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
te-1 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 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.
IILALTERNATIVES 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;
X A re -defined compliance boundary is needed for field(s) ID: 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.
W. 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

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 municipa lity, contra ctor, or other permitted entity. Furthermore, I certify that I have read this Agr eement,
understandthe 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. �1 �}
Landownername: biCkAe-5 E
Address: g0 L.),``e,0~ ` 4
City: \ Z-.3
nc r .,
Phone: \-1` V ,5o
Signature:
O. 1
NORTH CAROLINA, lAMMIGL COUNTY
State: Zip: Q13a
E-mail address:
Lu CeaCo-'c
Date:
I, the undersigned Notary Public do hereby certify that .S11a.rtL (initials: Yr ) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence Char/a E L ti- r s h signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and 3 offi ialsealthis the
Signature and seal: /L V7
My commission expires: 'Dec, 1 2.P2-
61,
Lessee's/Operator's Certification:
day of :144.61oaary , 20 ZZ
RORERT N. ROTII
NOTARY PI Irz rr
GUILFORD COUNTY
STATE OF NORTH CAROLINA
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as spec ied herein.
.,Lessee/operator name:
Address:
City: State: Zip:
Phone: E-mail address:
Signature:
Date:
Permittee's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name: S (live-
Signature:
Date: ///.3/)41 zi
FORM: LOA 06-16
Page 3 of 3

DWR
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: City of Burlington
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in 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-CH-251-3,4,5
No
Fescue
Hay/Pasture
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.
FORM: LOA 06-16
Page 1 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
,P-"\ 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 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 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;
X A re -defined compliance boundary is needed for field(s) ID: 3,5
(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

Lessee's/Operator'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
agreemeniwith anothermunicipality, 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. 1 /
Landowner name: 3 *Why et � e/ �` !� ` /
4 //
Address:
City:
F7 /V
Phone: 9/7
Signature: ire 6 �� Date:
NORTH CAROLINA,.
State: 4/C.
// Zip: ,4 73
E-mail address: D yAra-) m' ` C� ]
I, the undersigned Notary Public do hereby certify that
COLTNTY
L c.3
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sealthis the ( YA'
day of A 20 2 _ totiiiseigt�`l
Signature and seal: txDA
My commission expires:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and resin s��a°0k� erein.
ddLessee/op erafor name:
eyvAts
Address: t0rO koCULL VA
City:
r-5tt''0�
\c6-0
Phone: Oa)) +T`r'k`
Signature: C f
Permittee's Certification:
State:
Zip. Zri C Z
E-mail address:
C�L t :Ale 3mck- t. (of -
Date:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Signing official name: jlG r k'"""
Signature:
Date: is/, 3/2-d
FORM: LOA 06-16
Page 3 of 3

Site: NC-CH-251; Fields 1-5
sck Crotew
0
Feet
4,000 8,000
Legend
Subject Farm Boundary
Highways & Street Centerlines
GIS Division
Date: 1 /10/2022
BURLINGTON
Vicinity Map
1 in = 6,000 ft
UNC, Town of Cary;State of North Carolina DOT, Esri, HERE, Garmin,
" JNCREMENT P, USGS, METI/NASA; NGA; EPA, USDA
City of
.. _ G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primar
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

Site: NC-CH-251; Fields 1-5
ity of
RURLINGTON
1-' G.LS.
GIS Division
Date: 1 /11 /2022
*Note: Acreage calculated in GIS
Legend
C3Site Boundary
Q Property Line
4 4 I Application Area
Unsuitable
VA
X — Fence
• S.W.A.
• On Site House
▪ Off Site House
J Outbuildings
On Site Well
-0- Off Site Well
— — Streams
— Drains
Surface Water
Flood Zones:
AE
Floodway (AE)
0.2% Annual Chance Flood Hazard
Application Area Map
1 in = 660 ft
Disclaimer.
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy, which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

d
z
Site: NC-CH-251
(all locations approximate)
Topographic Map
1 inch = 1,000 feet

Site: NC-CH-251; Fields 1-5
Soil Map
1 in = 1,000 ft
Feet
750 1,500
Legend
Q Approved Application Fields
0 Field Numbers
GIS Division
Date: 1 /10/2022
City of
URLINGTON
. -- G.I.S.
Disclaimer:
This map was compiled from the GIS resources of the Burlington
Regional GIS Partnership for public planning and agency support
purposes. These resources include public information sources of
different scale, time, origin, definition and accuracy. which aspects
produce inconsistencies among features represented together on
this map. Neither the City of Burlington nor the Partnership shall
be held liable for any errors in this map or supporting data. Primary
public information sources from which this map was compiled, in
conjunction with field surveys where required, must be consulted
for the verification of the information contained within this map.

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DENR FORM FSF

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