NDRMPW-LAS-11-18

FORM: NDRMPW-LAS 11-18 Page 1 of 2
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS B RESIDUALS

AGREEMENT TO WAIVE SETBACKS PURSUANT TO
15A NCAC 02T .1108(c)
I, ___________________________________, certify that I am a deeded owner of the property located at:
Address: _________________________________________________ Parcel No.: __________________
City: ______________________________ State: ______ Zip Code: __________ County: _____________
Furthermore, I certify that I am authorized to make decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Permittee listed on the following
page.
For the parcel identified above, I consent to a reduced setback from _____ feet to _____ feet,
thereby allowing the application of Class B residuals as near as _____ feet from my property line.
For the parcel identified above, I consent to a reduced setback from _____ feet to _____ feet,
thereby allowing the application of Class B residuals as near as _____ feet from my residence.
**THIS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED**
Signature: ______________________________________________________ Date: _________________

FORM: NDRMPW-LAS 11-18 Page 2 of 2
Applicant/Permittee: ____________________________________________________________________
Address: _________________________________________________ Parcel No.: __________________
City: ______________________________ State: ______ Zip Code: __________ County: _____________
NORTH CAROLINA, __________________ COUNTY
I, ____________________________, a Notary Public for _______________ County, North Carolina,
do hereby certify that _______________________________ personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the _____ day of __________________, _____.

SEAL _______________________________________
Signature of Notary Public
My commission expires ___________________

Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded
waiver shall be sent to the following address:

Division of Water Resources
Non-Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617