WQ0004609_FP Att B_20111021

Beverly Eaves Perdue
Governor
NC®EN
North Carolina Department of Environment and Natural
Division of Water Quality
PAUL Nomm, COMPLEX MANAGER
WAS FARMS, LLC.
POST OFFJCF Box 383
DOBSON, NORTH CAROLINA 27017
Dear Mr. Nordin:
Coleen H. Sullins
Director
October 21, 2011
Resources
Bee Freeman
Secretary
Subject: Attachment B Certification
Permit No. WQ0004609
Wayne Farms LLC.
Land Application of Residual
Solids
Surry County
In accordance with your permit modification application package received on August 8, 2011, we
are forwarding herewith a modified Attachment B, certified October 21, 2011, to Wayne Farms, LLC, for
the subject residuals land application program.
This certification is being issued to modify the Attachment B by adding 246.2 acres (NC-SU-10
Fields 1-4 and NC-SU-13 Fields 1-10) and by deleting 25.7 acres (NC-SU-11 Fields 3 and 4, NC-SU-12
Field 1) of land application sites in Surry County.
Please note that a well is located and buffered inside the application area of NC-SU-13 Field 1.
If this well is permanently abandoned, a revised map is submitted to the Division, the setback around the
well can be removed.
Please replace the existing Attachment B of Permit No. WQ0004609 that was previously
certified on July 18, 2011, with this modified Attachment B. Note that only the vicinity and buffer
maps for any new and modified land application sites are attached to this modified Attachment B. It is
the Permittee's responsibility to ensure that a complete permit is created by insetting this modified
Attachment B and vicinity and buffer maps into Permit No. WQ0004609, issued on October 21, 2011,
and making sure to retain any vicinity and buffer maps for any existing and unmodified land application
sites.
This modified Attachment B shall be effective from the date of certification; shall void
Attachment B of Permit No. WQ0004609 that was previously certified on July 18, 2011; and shall be
subject to the conditions and limitations as specified therein and well as those specified in the above -
referenced permit. As always, remember to take the time to review this modified Attachment B
thoroughly, as some of the conditions contained therein may have been changed since the last
certification. Note that this modified Attachment B is hereby incorporated by reference into Permit No.
WQ0034397, issued on July 18, 2011.
AQUIFER PROTECTION SECTION
1636 N&' Service Center, Raleigh, North Carolina 27699-16K
Locatia^: 272 , Capital Bouievard. Raleigh, Norte Carolina 27664 Q v
Phone: [phone] FA,: I- 919-715-H,�B; FAX 2: 919 716-6G48 t Cus xner Sen1;,e:1-277-623-6748 � n
Internet: wwwmwatergualiN,om
Aa Ea Jr JAG^�iur••,. ': AhGr„arue r;c^�.�, Er„w_.,ye, b '�'R�L�,�r -
a

ATTACHMENT B - Approved Land Application Sites
Wayne Farms LLC.
Certification Date: October 21, 2011
Permit Number: WQ0004609 Version: 2.2
Field/ Site
Owner
Lessee
County
Latitude
Longitude
Aeret a
Dominant Soil Series
Footnotes
NC-SU-11-1
Bodenhamer, Bobby
Surry
36012'06"
80024'55"
11.3
Fairview
NC-SU-11-2
Bodenhamer, Bobby
Surry
36023'18"
80042'25"
7.6
Fairview
NC-SU-32-01
Templeton, Peter
Surry
36023'14"
80040'58"
9.2
Fairview
NC-SU-32-02
Templeton, Peter
Templeton, Peter
Surry
36023'20"
80041'12"
14.2
Pacolet
NC-SU-32-03
Templeton, Peter
Templeton, Peter
Surry
36023'37"
80041'l5"
5.9
Bethlehem
NC-SU-32-041
Templeton, Peter
Templeton, Peter
Surry
36023'43"
80041'10"
5.4
Bethlehem
NC-SU-32-05
Templeton, Peter
Templeton, Peter
Surry
3602342"
80041'15"
6.4
Bethlehem
NC-SU-32-06
Templeton, Peter
Templeton, Peter
Surry
36°23'55"
80°41'21"
2.6
Bethlehem
NC-SU-32-08
Templeton, Peter
Templeton, Peter
Surry
36023157"
80041'06"
15.3
Bethlehem
NC-SU-32-09
Templeton, Peter
'Templeton, Peter
Surry
36°2349"
80040'47"
16.8
Bethlehem
NC-SU-32-7A
Templeton, Peter
Templeton, Peter
Surry
36024'05"
80041T34"
13.8
Pacolet
NC-SU-32-7B
Templeton, Peter
Templeton, Peter
Surry
36034'03"
80041'24"
3A
Pacolet
NC-SU-35-02
Nichols, Harry
Nichols, Harry
Surry
36027`05"
80039'51"
9.1
Pacolet
NC-SU-35-04
Nichols, Hairy
Nichols, Harry
Surry
36027117"
80039'50"
7.3
Pacolet
NC--SU-8-1
Edmonds, Tommy
Surry
36°20'18"
80041'52"
15.0
Fairview
NC-SU-8-2
Draughn, Fern
Sung
36021111"
80040'25"
11.2
Fairview
NC-SU-8-3
Edmonds, Shirley
Surry
36°20'57"
80040'21"
21.7
Fairview
NC-SU-8-4A
Edmonds, Tommy
Sung
36022'19"
80041'22"
13.0
Fairview
NC-SU-8-413
Edmonds, Tommy
Surry
36022'25"
80041'14"
6A
Fairview
NC-SU-9-1
Simmons, Eugene
Surry
36026'33"
80040'12"
8.5
Fairview
NC-SU-9-2
Simmons, Eugene
Surry
36026136"
80040'23"
10.8
Fairview
NC-SU-9-3
Simmons, Eugene
Surry
36026'33"
80Q40'29"
13.1
Fairview
NC-SU-9 4
Simmons, Eugene
Surry
36-2634" 1
80-49-41"
13.0
Fairview
Page 1 of 2

ATTACHMENT B - Approved Land Application Sites
Wayne Farms LLC.
Certification Date: October 21, 2011
Permit Number: WQ0004609 Version: 2.2
Yield/ Site
Owner
Lessee
County
Latitude
Longitude
A rea e
Dominant Soil Series
Footnotes
NC-SU-9-5
Simmons, Eugene
Surry
36026'40"
80040'51"
9.3
Fairview
NC-SU-10-1
Simpson, Brent
Simpson, Brent
Surry
36023122"
80035'53"
21.7
Fairview
1,2
NC-SU-10-2
Simpson, Brent
Simpson, Brent
Surry
36023'23"
80036'14"
16.1
Fairview
1,2
NC-SU-10-3
Simpson, Brent
Simpson, Brent
Surry
36023'34"
80°35'26"
6.8
Fairview
1,2
NC-SU-10-4
Simpson, Brent
Simpson, Brent
Surry
36023'21"
80035'35"
12.9
Fairview
I,2
NC-SU-13-1
Johnson, Walter
Johnson, Walter
Sutry
36033'06"
80044'24"
35.2
Woolwine-Fairview-Westfield
NC-SU-13-2
Johnson, Walter
Johnson, Walter
Surry
3603PI6"
80044'29"
7.2
Woolwine-Fairview-Westfield
1
NC-SU-13-3
Johnson, Walter
Johnson, Walter
Surry
36031'14"
80044'13"
31.0
Woolwine-Fairview-Westfield
I
NC-SU-13-4
Johnson, Walter
Johnson, Walter
Surry
36031'01"
80044'15"
8.5
Woolwine-Fairview-Westfield
1
NC-SU-13-5
Johnson, Walter
Johnson, Walter
Surry
36031'02"
80043'54"
9.4
Woolwine-Fairview-Westfield
I
NC-SU-13-6
Johnson, Walter
Johlison, Walter
Surry
36030'45"
80043'44"
26.3
Braddock
I
NC-SU-13-7
Johnson, Walter
Johnson, Walter
Surry
36030'09"
80043'54"
17.5
Clifford
l
NC-SU-13-8
Johnson, Walter
Johnson, Walter
Surry
36'30'05"
8004342"
4.7
Clifford
1,3
NC-SU-13-9
Johnson, Walter
Johnson, Walter
Surry
36030'20"
80043'50"
7.2
Clifford
I
NC-SU-13-10
Dunbar, Joann
Johnson, Walter
Surry
36029'52"
80043'41"
41.7
Fairview
1,4
Total
496.5
I . A re -defined compliance boundary has been approved for this land application site. This re -defined compliance boundary is located 100 feet from the water supply well on the
property, Note that the 100-foot setback between wells and the land application area shall still be met.
2. A reduced setback from a residence under separate ownership has been approved for land application sites NC-SU40 Fields 1 through 4. Residuals miy be land applied within
100 feet of the residence owned by Gilmer Key (i.e., indicated by the label "A" on the approved setback map), Thomas Simmons (i.e., indicated by the label "B" on the approved
setback map), Elwin G. Key (i.e„ indicated by the label "C" on the approved setback map), and Donald Lynch (i.e., indicated by the label "ID" on the approved setback znap),
regardless of whether a surface or a subsurface application method is used.
3. A reduced setback from a residence under separate ownership has been approved for land application site NC-SU-13-8. Residuals may be land applied within 100 feet of the
residence owned by James W. Johnson (i.e., indicated by the label "A" on the approved setback map), Terry Hawks (i.e., indicated by the label "B" on the approved setback map),
regardless of whether a surface or a subsurface application method is used.
4. At this time there is an unoccupied/abandoned habitable residence located next to the northwest corner of this field that the landowner owns. If this habitable residence becomes
occupied the buffer maps shall be changed to reflect the required setbacks.
Page 2 of 2

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAIVER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
(THIS FORM mAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Quality (Division) will not accept this attachment unless all the instructions are
followed. Failure to submit all required items will lead to additional processing and review time.
For more information, visit our web site at.•htW://h2o.enr.state.nc.zrs/lau/maiia.htmI
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form:
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FORM: NDRLAP).
✓ Any changes to this attachment form will result in the application package being returned.
B. Prepare a separate attachment form for each property from which a waiver from 15A NCAC 2T
.1108(b)(2)(for habitable residences or place of public assembly) is being sought.
✓ Any other setbacks required by 15A NCAC 2T .1108, other than those referenced above, cannot be waived
through execution of this attachment form.
✓ A copy of the completed and appropriately executed attachment form must be provided to the property owner.
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 2T .1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Wavne Farms LLC
Complete mailing address of applicant: P.O. Box 383
City: Dobson State: NC Zip: 27017
Telephone number: ( 336 ) 386-8151 Facsimile number: ( 336 ) 386-8822
E-mail address:
hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less
than 100 feet) of the residence or place of.public assembly located atthe following:
Location address of property: 31651 XAQ2 �,�
Pr ��
City:- 11,12,44 -r State: XC Zip: G'� 2932— zZ
This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for
the residuals land application program and shall be renewed each time this permit is renewed. In addition,
this Agreement shall only remain in effect for as long as the undersigned property owner owns the property
described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,
given 30 calendar days in advance, modifies or cancels this Agreement.
® I certify that 1 am a deeded property owner of above -referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to land apply residuals to land
application site(s) as specified herein.
Property owner name:
Signature:
Date:
r
FORM: SWAA 070807 , Page I of I Attachment Order 3-d

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAIVER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
(THIS FORM MAYBE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Quality (Division) will not accept this attachment unless all the instructions are
followed. Failure to submit all required items will lead to additional processing and review time.
For more information, visit our web site at:hap:l/h2o.enr.state.nc.ars/laulmain.html
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form:
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FORM: NDRLAP).
✓ Any changes to this attachment form will result in the application package being returned.
B. Prepare a separate attachment form for each property from which a waiver from 15A NCAC 2T
.1108(b)(2)(for habitable residences or place of public assembly) is being sought.
✓ Any other setbacks required by 15A NCAC 2T .1108, other than those referenced above, cannot be waived
through execution of this attachment form.
✓ A copy of the completed and appropriately executed attachment form must be provided to the property owner.
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 2T .1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Wavne Farms LLC
Complete mailing address of applicant: P.O. Box 383
City: Dobson State: NC Zip: 270I7
Telephone number: ( 336 ) 386-8I.51 Facsimile number:( 336 ) 386-8822
E-mail address:
hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
Location address of property; Lz,7 cm fl'p_#,eA7— ke,+4
City: AeAky State: 14,�. Zip: o? W 17-
This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for
the residuals land application program and shall be renewed each time this permit is renewed. In addition,
this Agreement shall only remain in effect for as Iong as the undersigned property owner owns the property
described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,
given 30 calendar days in advance, modifies or cancels this Agreement.
® I certify that I am a deeded property owner of above -referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to land apply residuals to land
application site(s) as specified herein.
Property owner name: S �u
Signature: Date: gig �r --
0
FORM: SWAA 070807 Page 1 of I Attachment Order 3-d

L—lioz [ (7', Lei
State of North Carolina
Department of Environment and Natural Resources
-- Division of Water Quality
SETBACK WAIVER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
('PHIS FORMMAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Quality (Division) will not accept this attachment unless all the instructions are
followed. Failure to submit all required items will lead to additional processing and review time.
For more information, visit our web site at: htf ://h2o. enr•.state.nc.us/laulniain.html
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form:
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FORM: NDRLAP).
✓ Any changes to this attachment form will result in the application package being returned.
B. Prepare a separate attachment form for each property from which a waiver from 15A NCAC 2T
.1108(b)(2)(for habitable residences or place of public assembly) is being sought.
✓ Any other setbacks required by 15A NCAC 2T .1108, other than those referenced above, cannot be waived
through execution of this attachment form.
✓ A copy of the completed and appropriately executed attachment form must be provided to the property owner.
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 2T .1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Wayne Farms LLC
Complete mailing address of applicant: P.O. Box 383
City: Dobson State: NC Zip: 27017
Telephone number: ( 336 ) 386-8151 Facsimile number: ( 336 ) 386-8822
E-mail address:
hereinafter referred to as the Permittee, to Iand apply residuals within 100 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located atthefollowing:
Location address of property: 2-z5- 6U,w L f3iif _ r�
City: A/W-AE State: AIL Zip:
This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for
the residuals land application program and shall be renewed each time this permit is renewed. In addition,
this Agreement shall only remain in effect for as long as the undersigned property owner owns the property
described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,
given 30 calendar days in advance, modifies or cancels this Agreement.
® I certify that 1 am a deeded property owner of above -referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to land apply residuals to land
application site(s) as specified herein.
Property owner name: 52-WIlt( 6 .
Signature:
Date:�—
FORM: SWAA 070807 Page 1 of i Attachment Order-d

vd- iJafc_� zyarck
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAIVER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
(THIS FORM MAYBE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Quality (Division) will not accept this attachment unless all the instructions are
followed. Failure to submit all required items will lead to additional processing and review time.
For more information, visit our web site at:http _Ilh2 o. enr. state. nc. us/1aulmain. html
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form.
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FORM: NDRLAP).
✓ Any changes to this attachment form will result in the application package being returned.
B. Prepare a separate attachment form for each property from which a waiver from 15A NCAC 2T
.1108(b)(2)(for habitable residences or place of public assembly) is being sought.
✓ Any other setbacks required by 15A NCAC 2T .1108, other than those referenced above, cannot be waived
through execution of this attachment form.
+� A copy of the completed and appropriately executed attachment form must be provided to the property owner.
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY IBA NCAC 2T .1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Wayne Farms LLC
Complete mailing address of applicant: P.O. Box 383
City: Dobson State: NC Zip: 27017
Telephone number: ( 336 ) 386-8151 Facsimile number: ( 336 ) 386-8822
E-mail address:
hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly Iocated ,art�the following:
Location address of property: C2�' (9,57h& Amlt zfE
,
City: RARA' d State: /fol zip:.__ o2'7ZVq
This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for
the residuals land application program and shall be renewed each time this permit is renewed. In addition,
this Agreement shall only remain in effect for as long as the undersigned property owner owns the property
described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,
given 30 calendar days in advance, modifies or cancels this Agreement.
® I certify that I am a deeded property owner of above -referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to land apply residuals to Iand
application site(s) as specified herein.
Property oar name:
-7?Date:
FORM: SWAA 070807 C/ Page 1 of 1 Attachment Order 3-d

SYNAG,0
kPPIIICATION AREA MAP
rl
if
D MIF,
PL
A&"5 kt�z
0
0
a
A ,Residmair Management Company
� 7
ZI on
YY IJ►iY_
• ` 'fin
,4 -- Qdme e 41P- &WAA)
6- 1. 5'rWMM.5 (56VA A)
N
Owner igm,4 � i-- �IC�-,��l-%C�
Scale: V W 660' Field # cV
Total
Acres see sn =qn Net Acres (see surr qLa )
> STREAM CID
APPLICATION AREA — "'—' — -- - PRIVATE ROAD
---> DRAM'
HOUSE FORESTED AREA
CK) ❑
SURFACE WATER
OUTBUILDING UNSUITABLE
FENCE
WELL
O STORAGE AREA 0
SOIL DESCRIPTION SUITABLE FOR
INCORPORATION,
— I PROPERTY LINE
8-I2% SLOPE
The compliance boundary is established at either 250 feet from
the residuals application area or 50 feet within the property
boundary, whichever is closest to the application area. The review
boundary is established midway between the compliance
boundary and the perimeter of the residuals application area.

SYNAGP O
APPLICATION AREA MAP A. Ra.rid=Is[I,anagementCompany
Owner ruT f . ,��,�
Scale: 1." 660' Field #
_
Total
Acres (see Sut=axyi Net Acres (see summary)
STREAM CID
APPLICATION .AREA — — — — — - PRIVATE ROAD
�3 DRAM
HOUSE FORESTED AREA
CDSURFACE ❑
WATER
OUTBUILDING UNSUITABLE
FENCE
wELL
(D STORAGE AREA
SOIL DESCRIPTION SUITABLE FOR
� INCORPORATION,
PROPERTY LINE
8-12% SLOPE
The compliance boundary is established at either 250 feet from the residuals application area or 50 feet within the property
boundary, whichever is closest to the application area. The review boundary is estaolished midwalr between the compliance
boundary and the perimeter of the residuals application area.

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAIVER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Quality (Division) will not accept this attachment unless all the instructions are
followed. Failure to submit all required items will lead to additional processing and review time.
For more information, visit our web site at: http:111z2o. en1-. state. rzc. zis/lau/i7zair7. htmI
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form:
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FORM: NDRLAP).
✓ Any changes to this attachment form will result in the application package being returned.
B. Prepare a separate attachment form for each property from which a waiver from 15A NCAC 2T
.1108(b)(2)(for habitable residences or place of public assembly) is being sought.
✓ Any other setbacks required by 15A NCAC 2T .1108, other than those referenced above, cannot be waived
through execution of this attachment form.
✓ A copy of the completed and appropriately executed attachment form must be provided to the property owner.
AGREEMENT TO WANE THE SETBACK REQUIRED BY 1SA NCAC 2T .1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Wavne Farms LLC
Complete mailing address of applicant:
City: Dobson State: NC Zip: 27017
Telephone number: ( 336 ) 386-8151 Facsimile number: ( 336 ) 386-8822
E-mail address:
hereinafter referred to as the Perrnittee, to land apply residuals within 100 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
Location ad/d�re(ss of property: / �_ C� i'� vGe /C I �A e > e-<)
�/ 7� /tj °L Zip:
City: l I � _ State:
This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for
the residuals land application program and shall be renewed each time this permit is renewed. In addition,
this Agreement shall only remain in effect for as long as the undersigned property owner owns the property
described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,
given 30 calendar days in advance, modifies or cancels this Agreement.
® I certify that I am a deeded property owner of above -referenced property and am authorized to make decisions
regarding this property on 'behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Pennittee to land apply residuals to land
application site(s) as specified herein.
Property owner name:
-4
Si--nature:�t- (����✓ Date:
FORM: SWAA 070807 Page 1 of I Attachment Order S-d

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAIVER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
(THIS FORM MAY BE PHOTOCOPIED FOR USE 4S AN ORIGINAL)
The Division of Water Quality (Division) will not accept this attachment unless all the instructions are
followed. Failure to submit all required items will lead to additional processing and review time.
For more information, visit our web site at: htt :11h2o.ennstate.nc. us/lau/muin.htnil
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form:
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FORM: NDRLAP).
✓ Any changes to this attachment form will result in the application package being returned.
E. Prepare a separate attachment form for each property from which a waiver from 15A NCAC 2T
.1108(b)(2)(for habitable residences or place of public assembly) is being sought.
✓ Any other setbacks required by 15A NCAC 2T .1108, other than those referenced above, cannot be waived
through execution of this attachment form.
✓ A copy of the completed and appropriately executed attachment form must be provided to the property owner,
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 2T .1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Wavne Farms LLC
Complete mailing address of applicant: P.O. Box 383
City: Dobson State: NC Zip: 27017
Telephone number: ( 336 ) 386-8151 Facsimile number: ( 336 ) 386-8822
E-mail address:
hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
Location address of property: _fy/1D Awl__ %�/���f 1&/1`Q
City: MP4(11 i Allt T S tate: /</C-- Zip: 7d 3�
This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for
the residuals land application program and shall be renewed each time this permit is renewed. In addition,
this Agreement shall only remain in effect for as long as the undersigned property owner owns the property
described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,
given 30 calendar days in advance, modifies or cancels this Agreement.
® I certify that I am a deeded property owner of above -referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to land apply residuals to land
application sitc(s) as specified herein.
Property owner name: )A
Z-::, Signature:
0, Jo.
FORM: SWAA 070807 Page I of 1
Date;
Attachment Order 3-d

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAIVER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
(THIS FORM MAYBE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Quality (Division) will not accept this attachment unless all the instructions are
followed. Failure to submit all required items will lead to additional processing and review time.
For more information, visit our web site at:htaz:/1h2o.enr.state.nc.us/laulmain.htrnl
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form:
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FORM: NDRLAP).
✓ Any changes to this attachment form will result in the application package being returned.
B. Prepare a separate attachment form for each property from which a waiver from 15A NCAC 2T
.1108(b)(2)(for habitable residences or place of public assembly) is being sought.
✓ Any other setbacks required by 15A NCAC 2T .1108, other than those referenced above, cannot be waived
through execution of this attachment form..
✓ A copy of the completed and appropriately executed attachment form must be provided to the property owner.
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 2T .1108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name: Wayne Farms LLC
Complete mailing address of applicant: P.O. Box 383
City: Dobson State: NC Zip: 27017
Telephone number: ( 336 ) 386-8151 Facsimile number:( 336 )386-8822
E-mail address:
hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
Location address of property: E i &ze /�1:`'a/'�iGIkv �ff
City: meek d k1 4 State; �%[' Zip: %5
This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for
the residuals land application program and shall be renewed each time this permit is renewed. In addition,
this Agreement shall only remain in effect for as long as the undersigned property owner owns the property
described herein.
The undersigned property owner agrees to abide by this Agreement until such time as written notification,
given 30 calendar days in advance, modifies or cancels this Agreement.
® I certify that I am a deeded property owner of above -referenced property and am authorized to make decisions
regarding this property on behalf of other deeded property owners. Furthermore, I certify that I have read and
understand this Agreement and do hereby grant permission to the Permittee to land apply residuals to land
application site(s) as specified herein.
Property owner name: �
Signature: '7 !%�u' �2J Date:ir I I 1P
` {
FORM: SWAA 070807 Page I of l Attachment Order 3-d

&PLICATION AREA MAP
1 S 11 VAGP\O--
ARuidvais hfauragvwoCmrpany
Owner AIA1,42 s-U&6i 1112 64'-13
Scale: l" .= 660' Field # I
Total
Acres (see su zaly� Net Acres (see sunimat
—> STREAM CiD
AppLICATjoN AREA — _ PRIVATE ROAD
> DRAIN
HOUSE FORMI=D AREA.
SURFACE WATER ❑
OUTBUff DMG UNSUITABLE
t FENCE 0
INTILL
(D STORAGE ARM G)
SOIL DFScRirnoN SUITABLE FOR
Q9 INCORPORATION!,
PROPEIRi"YLTI\TE
8-12% SLOPE
The compliance boundary is established at either 250 feet from the residuais application area or 50 feetwithln the property
boundary, whichever is closest to the application area. The review boundary is established midway between the compliance
boundary and the perimeter of the residuals application area.

1�IN�
SYNAGRO
APPLIICATION AREA.. MAP
:A .Residuals 1blanagement Company
L
PL
EW
o�
rleo
1 � s
Acteas � '�
PL
Owner AZ—, C,4 & Z-,,W G -S1�-/ 3� Scale; 1" 660' Field #
Total Acres (see summaly�
Net Acres (see Summary)
—� STREAM APPLICATION .AREA '--
— -- — -- - PRIVATE ROAD
DRAIN HOUSE
FORESTED AREA
SURFACE WATER ❑ OT-JTBU]LDING
UNSUITABLE
n FENCE 0 WELL
(a) STORAGE. AREA SOIL DESCRIPTION
SUITABLE FOR
� INCORPORATIOlN,
PROPERTY LINE
5-12% SLOPE
The compliance boundary is established at either 250 feet from the residuals application area or 50 feet within the property
boundary, whichever is closest to the application area. The review boundary is established midway
between the compliance
boundary and the perimeter of the residuals application area.

APPLICATION AREA. MAP
mg
,4,-A SYNAG�
'A Rcsiducada Managam=r Company
Owner <61f4'-'l 25e C SZz-13 Scale: 1't = 660' Field
Total Acres (see summary)
Net .Acres (see surmnary�
—� STREAM APPLICATION AREA --
-- — -- -- - PRIVATE ROAD
�-� DRAIN HOUSE
FORESTED AREA
SURFACE WATER ❑ OUTBUILDING
UNSUITABLE
- n k FENCE WELL
STORAGE AREA G) SOIL DESCRIPTION
CD
SUITABLE. FOR
INCORPORATION_
PROPERTY LINE
5-12% SLOPE
The compliance boundary is established at either 250 feet from the residuals application area or 50 feet within the property
boundary, whichever is closest to the application area. The review boundary is established midway between the compliance
boundary and the perimeter of the residuals application area.

APPLICATION AREA MAP
SYNA_GR
't; Rasiduads Manngsv�wt Ccimpany
Owner
Seale: x" = 660' Field #
Total.
Acz es {see su m
Net Acres (see su:ntTlary
>
STREAMCiD
APPLICATION AREA `_ '—'
— — -.- .. PRIVATE ROAD
—�
DRAIN
®
HOUSE
FORESTED AREA
CDSURFACE
❑
WATER
OUTBUILDING
UNSUITABLE
FENCE
0
WELL
n
CD
STORAGE AREA
d
SOIL DESCRIPTION
SUITABLE FOR
� INCORPORATION,
PROPERTYLINE
8-12% SLOPE
The compliance boundary is established at either 250 feet from the residuals application area or 50 feet within the property
boundary, whichever is closest to the applications area. The -eview boundary is established midway between tht, compliance
boundary and the perimeter of the residuals application area.

�1P1
SYNAG
APPLICAATION AREA MAP
'A .8sszdudds Managmenp Company
Owner Al sa-%.3� Scale: 1" 660' Feld # 465� zj
t...���i'f•1't J1GL6i��U" C�C-J4•_!3_/f�)
Total Acres see su=aryNet Acres see su=q ri
--� STREAM APPLICATION AREA '— — — — - PRIVATE ROAD
> DRAIN HOUSE FORESTED AREA
CDSURFACE WATER ❑ OUTBUILDING UNSUITABLE
FENCE n n � l/ 1 WELL
CDSTORAGE AREA SOIL D CRIPTION SUITABLE FOR
!3 -SRm i �5 � frA) INCORPORATION',
PROPERTYLINE S-7C�'�`l S-I2% SLOPE
The compliance boundary is established at either 250 feet from the residuals application area or 50 feet within the property
boundary, whichever is closest to the application area. The review boundary is established midway between the compliance
boundary and the perimeter of the residuals application area.