WQ0000520_FP AttB_20120106

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MCDEHR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
MR. HAROLD T. OWEN, CITY MANAGER
CITY OF BURLINGTON
POST OFFICE BOX 1358
BURLINGTON, NORTH CAROLINA 27216
Dear Mr. Owen:
Division of Water Quality
Charles Wakild, P. E.
Director
January 6, 2012
Dee Freeman
Secretary
Subject: Attachment B Certification
Permit No. WQ0000520
City of Burlington Residual Land
Application Program
Alamance County
In accordance with your permit modification application package received on August 31, 2011 as
well as the additional information received on November 29, 2011; we are forwarding herewith a
modified Attachment B, certified January 6, 2012, to the City of Burlington for the subject residuals land
application program.
This certification is being issued to modify the Attachment B by deleting 213.3 acres (Fields NC -
AM -3-3, NC -AM -57-1, NC -AM -99-1, NC -AM -103-1, NC -AM -109-3, NC -AM -122-1, NC -CH -97-2,
NC -CH -150-1,2,3,4,5, and NC -CS -114-1), transferring 77.6 acres from Permit WQ0004033 (Fields NC -
OR -74A, NC -OR -7-1B, NC -OR -7-2 and NC -OR -64-13), adding.644.7 acres in Alamance, Caswell and
Chatham counties and modifying 5.7 acres (Fields NC -CS -2,3,4,5, NC -CH -39-1,2 and NC -CH -40-1) of
land application area. Each field is uniquely identified; please ensure that when submitting reports each
field identification number matches the one listed on the most recently certified Attachment B.
Please replace the existing Attachment B of Permit No. WQ000000520 that was previously
certified on September 16, 2010, 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 inserting this modified
Attachment B and vicinity and buffer maps into Permit No. WQ0000520, issued on January 6, 2012,
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. WQ0000520 that was previously certified on September 16, 2010; and shall
be subject to the conditions and limitations as specified therein and well as those specified in the above -
1617 Mail Service Center, Raieiah, North Caroline 27698-1617
Location: 512 h:. Salisoury St. Raleiah, North Carolina 27604
Prion: 919-80r 1 -877 -62s -674F,
Iriterne:: www.nmateraualltv.Oro
mi'Qua: Ducnunit, t ,lvmanve;, nen Emniov.<'
On-,
rCaroli na

Mr. Owen
January 6, 2012
Page 2 of 2
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.
WQ0000520, issued on January 6, 2012.
If any parts, requirements, and/or limitations contained in this certification or modified
Attachment B are unacceptable, you have the right to request an adjudicatory hearing upon written
request within 30 days following receipt of the certification. This request shall be in the form of a written
petition, conforming to Chapter 150B of the North Carolina General Statutes and filed with the Office of
Administrative Hearings at 6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless such
demands are made, this permit shall be final and binding.
If you need any additional information concerning this matter, please contact Alice M. Wessner
by telephone at [phone] (at 807-6425 after January 6, 2012) or via e-mail at
alice.wessner(aincdenr. vov.
Sincerely,
ZChari akild, P.E.
cc: James Blackwell, Synagro Central LLC. 284 Boger Road, Mocksville, North Carolina 27028
Alamance County Health Department
Caswell County Health Department
Chatham County Health Department
Orange County Health Department
Raleigh Regional Office, Aquifer Protection Section
Winston Salem Regional Office, Aquifer Protection Section
APS Permit File WQ0000520
Notebook File WQ0000520

ATTACH vagi NT B - Approved Land Application Sites
Permit Nuuber: `VQ0000520 Version: 2.3
Cite of Burlington
City of Burlington Residuals Land Application Program
Certification Date: 01/06/2012
Field/Zone Id
Owner
Lessee
County
Latitude
Longitude
Net Acreage
Dominant Soil Series
NC -AM -002-01
Culberson, Kenneth C
Alamance
35°53'56"
79°28'52"
6.60
Davidson
NC -AM -002-02
Culberson, Kenneth C
Alamance
3554'06"
79°28'52"
13.40
Davidson
NC -AM -002-03
Culberson, Kenneth C
Alamance
35°54'05"
79028'47"
6.70
Davidson
NC -AM -002-04
Culberson, Kenneth C
Alamance
35°54'04"
7928'42"
6.70
Davidson
NC -AM -002-05
Culberson, Kenneth C
Alamance
3553'60"
79028'35"
7.60
Iredell
NC -AM -002-06
Culberson, Kenneth C
Alamance
35°53'52"
79°28'33"
9.30
Iredell
NC -AM -002-07
Culberson, Kenneth C
Alatnance
35°53'52"
7928'39"
6.20
Iredell
NC -AM -002-08
Culberson, Kenneth C
Alamance
35°53'50"
79°28'46"
4.70
Iredell
NC -AM -002-09
Culberson, Kenneth C
Alamance
35°53'43"
79528'37"
6.50
Iredell
NC -AM -003-01
Graves, Jaime E
Johnson, Joseph
Alamance
35°54'27"
7924'58"
30.40
Geor eville
NC -AIV! -003-02
Graves, Jaitne E
Johnson, Joseph
Alamance
35°54'32"
7924'47"
36.60
Li null
NC -AM -003-04
Graves, Jaime E
Johnson, Joseph
Alamance
35°54'14"
7924'50"
24.40
Li num
NC -AM -004-01
Zachary, George
Alamance
35°52'50"
79°19'38"
16.80
Masada
NC -ANI -004-02
Zachary, George
Alamance
3553'08"
79°19'43"
14.10
Geor eville
NC -AM -005-01
Griffin, Larry F
Alamance
35°52'50"
79°24'32"
1.80
Li tum
NC -AM -005-02
Griffin, Larry F
Alamance
35°52'55"
79024'24"
11.20
Li num
NC -AM -006-01
Hessentltaler, Walter
Neal, W Tom
Alamance
35°52'27"
79°30'05"
16.20
Helena
NC-Alvl-006-02
Hessenthaler, Walter
Neal, W Tom
Alamance
35°52'21"
79°30'09"
18.20
Appling
NC -AM -006-03
!Hinshaw, Fred
Hessentltaler, Walter
Alatnance
3552'07"
79°30'18"
5.50
Appling
NC -AM -006-04
Hessenthaler, Walter
Neal, W Tom
Alamance
35°51'17"
79°31'26"
10.10
Davidson
NC -AM -006-05
Hessenthaler, Walter
Neal, W Tom
Alamance
35°51'26"
79°31'27"
39.00
Cecil
NC -ANI -006-08
Neal, W Tom
Hessenthaler, Walter
Alamance
35°52'47"
79°30'19"
10.40
Appling
NC -AM -006-09
Neal, W "font
Hessentlialer, Walter
Alamance
35°52'34"
79°30'21"
14.30
Appling
NC -AM -006-10
Applebaum, Richard
Hessentltaler, Walter
Alamance
35°52'24"
79°30'21"
21.10
Appling
NC -AM -007-01
Teague, Michael C
Alamance
35°53'19"
79°29'24"
17.70
Mecklenburg
NC-Arvl-007-02
Teague, Michael C
Alamance
35°53'21"
79°29'15"
21.30
Mecklenburg
NC -AM -008-01
Staley, Jinuny
Alamance
35°58'33"
79°21'34"
18.70
Sedgefield
NC -AM -013-01
Tinnin, Kathleen
Hadley, James
Alamance
35°53'11"
79°21'32"
13.10
Geor eville
NC-AIvl-013-02
Tinnin, Kathleen
Hadley, James
Alamance
35°52'48"
79°21'45"
17.50
Geor eville
NC -Alva -013-03
Tinnin, Kathleen
Hadley, James
Alamance
35°53'01"
79°21'39"
41.00
Geor eville
NC -ANI -014-01 1•2
Roney, James A.
Roney, James A.
Alamance
36°08'58"
79-19'00"
34.50
Helena
NC -AM -014-02
Roney, James A.
Roney, James A.
Alamance
3608'43" 1
79018'13"
12.90
Helena
NC -AM -014-03
Roney, James A.
Roney, James A.
Alamance
36°09'12"
79°18'42"
10.00
Melena
NC-AM-014-04�
Turner, Carolyn R.
Roney, James A.
Alamance
36°09'01"
7918'41"
29.80
Helena
NC-AIvl-014-05
Roney, James A.
Roney, James A.
Alamance
36°08'50"
7918'47"
20.40
Enon
Page 1 of 8

K
ATTACHMENT B - Approved Laud Application Sites
Permit Number: WQ0000520 Version: 2.3
City of Burlington
Citv of Burlington Residuals Land Application Program
Certification Date: 01/06/2012
Field/Zone Id
Owner
Lessee
County
Latitude
Longitude
Net Acreage
Dominant Soil Series
NC-AM-Ut5-01
Wyatt, Charlie A.
Watt, Charlie A.
Alamance
36°09'59"
79°20'55"
14.30
Vance
NC -AM -015-021
Watt, Charlie A.
Watt, Charlie A.
Alamance
36009'42"
79°20'54"
12.20
Enon
NC -ANI -015-03
Watt, Charlie A.
Wyatt, Charlie A.
Alamance
36°09'29"
79°20'51"
8.70
Enon
NC-AIVI-015-04�
Watt, Charlie A.
Watt, Charlie A.
Alamance
36°09'28"
79020134"
17.80
Cecil
NC -AM -016-013
IIadley, C.L.
Hadley, Michael T.
Alamance
35°51'36"
79021129"
31.80
Herndon
NC -AM -U16-023
Hadley, C.L.
Hadley, Michael T.
Alamance
35°51'19"
79°21'52"
26.70
Alamance
NC -AM -016-034
Hadley, C.L.
Hadley, Michael T.
Alamance
35°51'28"
79°22'17"
30.50
Georgeville
NC-AM-Ol6-04'4
Hadley, Russell
Hadley, Michael T.
Alamance
35051'17"
79°21'30"
31.10
Henidon
NC -AM -016-05
Hadley, Russell
Hadley, Michael T.
Alamance
35°50'47"
79°21'40"
15.30
Georgeville
NC -AM -016-061
Hadley, Russell
Hadley, Michael T.
Alamance
35050'55"
79022'46"
21.60
Herndon
NC -AM -017-01
Bell, Frank
Bell, Frank
Alamance
36°12'18"
79°28'51"
13.60
Iredell
NC -AM -017-021.5
Bell, Frank
Bell, Frank
Alamance
36°12'19"
79°28'36"
31.10
Iredell
NC -AAI -017-031•`
Bell, Frank
Bell, Frank
Alamance
36°12'16"
79°28'19"
25.80
Iredell
NC -AM -017-04
Bell, Frank
Bell, Frank
Alamance
36°1216"
79°28'09"
3.80
Helena
NC -AM -018-01 1''
Mills, Albert Stafford
Mills, Albert Stafford
Alamance
36°10'08"
79°265'37"
27.30
Iredell
NC-ANI-018-02�
Mills, Albert Stafford
Mills, Albert Stafford
Alamance
360t0'l2"
79°26'32"
8.20
Iredell
NC -AM -018-03
Mitis, Albert Stafford
Mills, Albert Stafford
Alamance
35°10'09"
79°26'12"
10.20
Iredell
NC -AM -035-01
Rice, Joseph M
Alamance
35°51'39"
79°22'06"
6.80
Georgeville
NC -AM -035-02
Rice, Joseph M
Alamance
35°51'43"
79°22'02"
12.40
Georgeville
NC -ANI -035-03
Rice, Joseph M
Alamance
35°51'48"
79°21'49"
23.40
Georgeville
NC -AM -035-04
Rice, Joseph M
Alamance
35°51'36"
79°21'49"
19.50
Georgeville
NC -AM -035-05
Rice, Joseph M
Alamance
35°51'49" 1
79°21'31"
31.90
Georgeville
NC-ANl-055-02
Pegg, Ruth
Rice, Joseph M
Alamance
35°52'07"
79°22'25"
3.70
Georgeville
NC -AM -055-U3
Pegg, Ruth
Rice, Joseph M
Alamance
35°52'00"
79°22'19"
5.70
Georgeville
NC -AAI -055-04
Pegg, Ruth
Rice, Joseph M
Alamance
35°52'08"
79°22'12"
2.50
Georgeville
NC -AM -055-05
Pegg, Ruth
Rice, Joseph M
Alamance
35°52'04"
79°21'37"
22.00
Georgeville
NC -ANI -058-01
Sarvay, Amy II
Newlin, Leonidas B
Alamance
35°52'30"
79°1734"
8.20
Georgeville
NC -ANI -072-01
Justice, Harold D
Alamance
35°51'59"
79°21'51"
6.20
Georgeville
NC -AM -072-02
Justice, Harold D
Alamance
35°52'06"
79°21'50"
10.00
Georgeville
NC -ANI -073-01
Newlin, Leonidas B
Alamance
35°52'30"
79°17'46"
20.00
Tatum
NC -AM -073-02
Newlin, Leonidas B
Alamance
35°52'39"
79°17'47"
7.20
Georgeville
NC -ANI -073-03
Newlin, Leonidas B
Alamance
35°52'54"
79°17'54"
9.60
Georgeville
NC -ANI -098-01
McPherson, F C
Alamance
35°55'18
79028'04"
19.00
Georgeville
Page 2 of 8

ATTACH TIENT B - Approved Land Application Sites
Permit Number: WQ0000520 Version: 2.3
City of Burlington
City of Burlington Residuals Land
rata
Certification Date: 01/06/2012
Field/Zone Id
Owner
Lessee
County
Latitude
Longitude
Net Acreage
Dontinant Soil Series
NC -AM -098-02
McPherson, F C
Alamance
35°55'25"
7928'27"
38.00
Cecil
NC -AM -098-04
McPherson, Eric
Alamance
3553'41"
7926'47"
42.00
Geor eville
NC -AM -100-01
McPherson, Ten
Alamance
3552'41"
79°15'20"
30.00
Cecil
NC-AIvl-109-01
McQueen, Chapman T
Thompson, Lonnie Blair
Alamance
35°56'35"
7920'41"
16.20
Ilelena
NC-ANI-lU9-02
McQueen, Chapman T
Thompson, Lonnie Blair
Alamatice
35°56'49"
79'20'37"
6.50
Ilelena
NC -AM- 110-01
Newlin, Leonidas B
Alamance
35°53'02" 1
79017'35"
28.20
Geor eville
NGAM-110-02
Newlin, Leonidas B
Alamance
35°52'54"
79°17'41"
9.00
Geor eville
NC -AM -116-01
Byrd, H W
Alamance
35°54'01"
79°23'19"
19.30
Tatum
NC-Alvl-116-03
Byrd, H W
Alamance
35°54'11"
79°23'24"
45.30
Ma yodan
NGAM-116-04
Byrd, H W
Alamance
35°54'24"
79°23'24"
29.40
Tatum
NGAM-116-05
Byrd, 11 W
Alamance
35°54'23"
79°23'26"
51.50
Tatum
NCAM-116-06
Byrd, 11 W
Alamance
35°54'31"
79°23'54"
11.60
Tatum
NC -AAI -116-07
Byrd, 11 W
Alamance
35°54'21"
7923'52"
81.50
Tatum
NC -AAI -1 16-08
Byrd, 11 W
Alamance
35°54'15"
7924'10"
71.60
Ma odan
NCAM-I 16-09
Byrd, H W
Alamance
35°52'33"
7926'50"
44.90
Geor eville
NC-Alvl-116-10
Byrd, 11 W
Alamance
35°52'43"
79°26'53"
12.90
Geor eville
NC-AN,l-116-11
Byrd, H W
Alamance
35°52'40"
79°26'37"
49.80
Geor eville
NC-AN,I- 116-12
Byrd, 11 W
Alamance
3552'47"
79°26'38"
32.00
Geor eville
NC-Alvl-116-13
Byrd, H W
Alamance
3553'01"
79°26'54"
53.30
Geor eville
NC-Afvl-I 18-01
Stephens, Simon Ross
Alamance
36°51'20"
79°27'03"
28.00
Herndon
NC -AM -118-02
Stephens, Simon Ross
Alamance
36°51'18"
79°26'43"
13.00
Herndon
NC -AAI - I 18-03
Stephens, Simon Ross
Alamance
36°51'18"
79°26'34"
16.00
Herndon
NC -AM -118-04
Stephens, Simon Ross
Alamance
36°51'09"
79°26'47"
22.00
flerndon
NC -AM -118-05
Stephens, Simon Ross
Alamance
36°50'59"
79026'51"
12.00
Herndon
NC -AM -118-06
Stephens, Sinton Ross
Alamance
36°51'04" 1
79°27'03"
30.00
Geor eville
NGAM-118-07
Stephens, Simon Ross
Alamance
36°50'52"
79°26'57"
7.00
Herndon
NGAM-118-08
Stephens, Simon Ross
Alamance
36°50'59"
79°26'26"
11.00
Herndon
NC-AIvl-118-09
Stephens, Simon Ross
Alamance
36'51'05"
79°26'17"
25.50
Altavista
NC -AM -118-10
Stephens, Simon Ross
Alamance
36°51'28"
7926'56"
3.40
Herndon
NC -AM -119-01
Kiser, Nelda Stephens
Alamance
35°50'41"
79°26'24"
20.30
Herndon
NC -AM -119-02
Kiser, Nelda Stephens
Alamance
35°50'43"
7926'38"
20.00
Ilerndon
NC -AM -120-01
Cartner, Max Russell
Cartner, Max Russell
Alamance
35°56'U1"
79°19'13"
11.00
Helena
NC -AM -121-01
Cashwell, Edgar A
Cartner, Max Russell
Alamance
35°56'06"
79"19'25"
9.00
Melena
NC -AAI -123-01
Cheek, Elwood P
McPherson, Ter
Alamance
35"55'50"
79°19'09"
10.00
Durham
NC -AM -125-01
McPherson, Billy
McPherson, Te
Alamance
35°52'41"
79°15'59"
21.40
Tatum
Page 3 of 8

A'T'TACHMENT B - Approved Land Application Sites
Permit Number: WQ0000520 Version: 2.3
City of Burlington
Citv of Burlinston Residuals Land Application Proerau)
Certification Date: 01/06/2012
Field/Zone 1d
Owner
Lessee
County
Latitude
Longitude
Net Acreage
Dondnaut Soil Series
NC -AM -125-02
McPherson, Billy
McPherson, 'Ferry
Alamance
35°52'47"
79°15'48"
8.00
Tatum
NC -AM -125-03
McPherson, Billy
McPherson, Terry
Alamance
3552'43"
79°15'45"
13.80
Geor eville
NC -AM -125-04
McPherson, Billy
Fogleman, Chad
Alamance
35°52'43"
79'1545"
3.70
Tatum
NC -AM -126-01
Ashley, Alvali T
Fogleman, Chad
Alamance
35°52'57"
79'27'24"
10.10
Wedowee
NC -AM -126-02
Ashley, Alvalt T
Fogleman, Chad
Alamance
35°52'45"
79°27'18"
7.60
Geor eville
NC -AM -126-03
Ashley, Alvalt T
Fogleman, Chad
Alamance
35°52'36"
79'27'23"
32.00
Geor eville
NC-Alv1-126-04
Ashley, Alvah ,r
Fogleman, Chad
Alamance
35'52'42"
79'27'38"
9.80
Helena
NC -AM -126-05
Fogleman, Larry
Fogleman, Chad
Alamance
35'52'60"
79'29'21"
10.50
Geor eville
NC -AM -126-06
Fogleman, Larry
Fogleman, Chad
Alamance
35'53'01"
79'29'19"
9.50
Geor eville
NC-Alvl-126-07
Fogleman, Larry
Alamance
35'53'06"
79'29'34"
6.30
Geor eville
NC -AAAI -126-08
Fogleman, Chad
Fogleman, Chad
Alamance
35'53'08"
79'29'19"
11.60
Wedowee
NC -AM -126-09
Ashley, Pauline Carter
Fogleman, Chad
Alamance
35'53'21"
79'27'45"
16.60
Cecil
NC -AM -126-10
Ashley, Pauline Carter
Thompson, Blair
Alamance
35'53'24"
79'27'38"
30.50
Davidson
NC -AM -127-01
Thompson, John
Alamance
35'57'17"
79'21'23"
14.90
Melena
NC-Atyl-128-01
Land, C E
Alamance
36'I4'26"
79'3l'OI"
38.00
Melena
NC -AM -128-02
Land, C E
Alamance
36'14'19"
79'30'53"
5.00
Helena
NC -ANI -128-03
Land, C E
'Alamance
36'14'19"
79'30'42"
13.60
Appling
NC-Alv1-128-04
Land, C E
Alamance
36°14'19"
79'30'32"
11.10
Iredell
NC -ANI -128-05
Land, C E
Alainance
36'14'42"
79'30'37"
9.90
Melena
NC -AM -I28-06
Land, C E
Alamance
36'14'33"
79'30'17"
63.30
Ilelena
NC-AIv1-128-07
Land, C E
Alantance
36'14'45"
79'31'00"
15.00
Badin
NC-Arvl-129-01
McCauley, Dorothy
Whitlow, Jim
Alamance
36'12'32"
79'18'51"
7.40
Melena
NC -ANI -129-02
McCauley, Dorothy
Whitlow, Jim
Alamance
36'12'36"
79'18'47"
7.30
Vance
NC-AIvl-129-03
McCauley, Dorothy
Whitlow, Jim
Alamance
36'12'24"
79'18'45"
3.90
Vance
NC -AM -129-04
McCauley, Dorothy
Whitlow, Jim
Alamance
36'12'18"
79'18'40"
10.90
Vance
NC -ANI -129-06
McCauley, Dorothy
Whitlow, Jim
Alamance
36'12'29"
79'18'30"
7.40
Vance
NC -AM -129-07
McCauley, Dorothy
Whitlow, Jim
Alamance
36'12'24"
79'18'25"
5.40
Helena
NC -AAI -129-08
McCauley, Dorothy
Whitlow, Jin)
Alamance
36'12'15"
79'18'19"
3.70
Rion
NC-AIVI-129-09
McCauley, Dorothy
Whitlow, Ain
Alamance
36'12'09"
79'18'28"
5.10
Melena
NC -AM -129-10
McCauley, Dorothy
Whitlow, Jim
Alamance
36't2'06,,
79018'37"
11.10
Mecklenburiz
NC-AIvl-129-11
Cobb, Ronald "T And Sarah W
Whitlow, Jim
Alamance
36'11'51"
79'18'31"
2.70
Mecklenbur
Total For County
Alamance
2,451.10
Geor eville
NC -Cil -039-01
Brewer, James B
Brewer, James B.
Chatham
35'47'92"
79'23'35"
15.00
Geor eville
NC -CII -039-02
Brewer, James B
Brewer, James B.
Chatham
35'47'00"
79'24'03"
12.80
Geor eville
NC -CII -039-03
Brewer, James B
Brewer, James B.
Chatham
35'47'92"
79'24'16"
15.70
Cid-Li num
Page 4 of 8

ATTACH WENT13 - Approved Laud Application Sites
['ermit Number: WQ0000520 Version: 2.3
City of Burlington
Citv of Burlivaton Residuals Laud Avulication Program
Certification Date: 01/06/2012
Field/Zone Id
Owner
Lessee
County
Latitude
Longitude
Net Acreage
Dominant Soil Series
NC-CII-039-04�
Brewer, James B
Brewer, James B.
Chatham
35°46'40"
79°24'15"
15.90
Georgeville
NC -CII -040-011
Brewer, James B
Brewer, James B.
Chatham
35°46'55"
79°24'15"
33.40
Georgeville
NC-Cl1-095-01
Moon, Gary 11
Chatham
3550'19"
79°24'37"
16.90
Nanford
NC -CH -095-02
Moon, Gary 11
Chatham
35°50'15" 1
79°24'43"
9.10
Georgeville
NC -CII -095-03
Moon, Gary H
Chatham
35°50'16"
79°24'50"
12.70
Georgeville
NC -CII -095-04
Moon, Gary H
Chatham
3550'21"
7924'59"
9.00
Cid
NC -CII -095-05
Moon, C;aiy H
Chatham
35°50'27"
7924'59"
9.50
Cid
NC -Cl -l-095-06
Moon, Gary H
Chatham
35°50'30"
7925'04"
11.50
Georgeville
NC -CII -095-08
Moon, Gary I1
Chatham
35050'07"
79°24'54"
8.60
Nason
NC -CII -098-01
Brookbank, William H
Chatham
35°49'52"
79026'49"
.60
Cid
NC -CII -098-02
Brookbank, William 11
Chatham
3549'58"
79°26'51"
5.50
Badin
NC -CII -098-03
Brookbank, William H
Chatham
35°50'06"
79°26'42"
11.30
Li num
NC -CH -098-04
Brookbank, William H
Chatham
3550'32"
7926'36"
24.30
Badin
NC -CII -098-05
Brookbank, William H
Chatham
35°50'19"
79026'30"
11.30
Badin
NC -CII -098-06
Brookbank, William H
Chatham
3550'07"
7926'37"
9.60
Li num
NC -CII -098-07
Brookbank, William H
Chatham
35°49'59"
79°26'28"
16.30
Li num
NC -CII -098-08
Brookbank, William H
Chatham
35°49'54"
79'26'13"
27.00
Li num
NC -CII -098-09
Brookbank, William H
Chatham
35°4948"
79026'24"
28.00
Lignum
NC -CH -098-10
Brookbank, William 11
Chatham
3549'54"
79°26'41"
35.10
Li num
NC -CH -099-01
Culberson, Shelby
Chatham
3547'34"
79'25'30"
11.70
Georgeville
NC -CII -099-02
Culberson, Shelby
Chatham
35°47'38"
79°25'22"
5.30
Badin
NC -CII -251-U1
Lutterloh, Charles S
Chatham
35047'53"
79014'09"
27.00
Nanford
NC -CII -251-02
Lutterloh, Charles S
Chatham
35°47'42"
79°14'16"
11.60
Georgeville
NC -CII -251-03
Lutterloh, Charles S
Chatham
35°47'59"
79°14'19"
31.60
Georgeville
NC -CII -251-04
Lutterloh, Charles S
Chatham
35°48'01"
79°14'28"
5.40
Nanford
NC -CII -251-U5
Lutterioli, Charles S
Chatham
35°47'50"
79°14'29"
23.50
Nanford
Total For County
Chatham
455.20
NC -CS -017-01R
Bell, Frank
Bell, Frank
Caswell
36°15'55"
7921'08"
28.40
Cecil
NC -CS -0 17-02
Bell, Frank
Bell, Frank
Caswell
36015'32"
79°21'14"
35.10
Cecil
NC -CS -017-03
Bell, Frank
Bell, Funk
Caswell
36015'18"
79°21'14"
19.60
Helena
NC -CS -017-049,W,11
Bell, Frank
Bell, Frank
Caswell
3615'03"
79°21'06"
43.40
Helena
NC -CS -018-01
Allred, Delmar W.
Simmons, Dermis
Caswell
36°16'21" 1
79024'38"
32.10
Appling
NC -CS -036-01
Simmons, Dennis A
Caswell
3616'59"
7926'57"
4AU
Mecklenburg
NC -CS -036-02
Simmons, Dennis A
Caswell
36°16'49"
7926'56"
3.10
Lnon
Page 5 of 8

AT"rAC11111EN'T B - Approved Land Application Sites
1'ermit Number: NVQ0000520 Version: 2.3
City of Burlington
Citv of Burlington Residuals Land Application Program
Certification Date: 01/06/2012
Field/Zone Id
Owner
Lessee
County
Latitude
Longitude
Net Acreage
llonuuaut Soil Series
NC -CS -036-03
Sinunons, Dermis A
Caswell
36'16'55"
79°26'57"
2.30
Cullen
NC -CS -036-04
Simmons, Demris A
Caswell
36°16'54"
79°26'53"
5.30
Mecklenburg
NC -CS -036-05
Simmons, Demris A
Caswell
36°17'03"
79°26'40"
15.00
Enon
NC -CS -036-06
Simmons, Dermis A
Caswell
36°16'26"
79°25'39"
18.00
Pacolet
NC -CS -036-07
Sinmrons, Dennis A
Caswell
3616'38"
79'2542"
18.90
Enon
NC -CS -036-08
Simmons, Demris A
Caswell
36°16'38"
79'25'35"
12.90
Enon
NC -CS -036-09
Sinunons, Dennis A
Caswell
36°16'43"
79°25'30"
6.00
Enon
NC -CS -036-10
Simmons, Dennis A
Caswell
36°16'40"
79°25'13"
17.20
Mecklenburg
NC -CS -036-11
Simmons, Demris A
Caswell
36'16'41"
79'24'55"
26.40
Enon
NC -CS -036-12
Sinunons, Dennis A
Caswell
36'16'25"
79'25'02"
24.00
Enon
NC -CS -113-U1
Simmons, Douglas
Caswell
36'17'45"
79'26'42"
12.00
Geor eville
NC -CS -113-02
Simmons, Douglas
Caswell
36'17'39"
79'26'18"
13.60
Lloyd
NC -CS -113-03
Simmons, Douglas
Caswell
36'18'17"
79'26'33"
31.00
Lloyd
NC -CS -113-04
Simmons, Douglas
Caswell
36'18'18"
79'26'57"
29.40
Efland
NC -CS -113-U5
Simmons, Douglas
Caswell
35'18'09"
79'26'38"
8.50
Pacolet
NC -CS -116-01
Miles, Ervin
Caswell
36'18'40"
79'24'10"
12.50
Appling (wedowee)
NC -CS -116-02
Miles, Ervin
Caswell
36'18'20"
79024'12"
8.00
Cecil
NC -CS -116-03
Miles, Ervin
Caswell
36'18'21"
79024'18"
11.30
Helena
NC -CS -I 16-04
Miles, Ervin
Caswell
36'18'32"
79'24'22"
12.60
Appling (wedowee)
NC -CS -116-05
Miles, Ervin
Caswell
36'18'36"
79'24'24"
2.50
Wedowee
NC -CS -117-01
Blanclr/J.C. Jefferies Trust
Randleman, Chad
Caswell
36'16'20"
79'26'34"
16.90
Cecil
NC -CS -117-02
Jefferies, Blanche S.M.C.
Randleman, Chad
Caswell
36'16'16"
79'2623"
9.60
lredell
NC -CS -117-03
Jet cries, Blanche S./J.C.
Randleman, Chad
Caswell
36'16'04"
79'26'11"
25.80
lredell
NC -CS -117-04
Jefferies, Blanche S./J.C.
Randleman, Chad
Caswell
36'16'03"
79'26'01"
10.90
lredell
NC -CS -117-051
Jefferies, Blanche SA.C.
Randleman, Chad
Caswell
36'16'04"
79'26'25"
23.10
lredell
Total For County
Caswell
1
539.80
NC -GU -026-08
Land, C E
Guilford
36014'23"
79'33'31"
29.00
Mecklenbur
NC -GU -026-09
Land, C E
Guilford
36'14'36"
79'33'15"
14.20
Mecklenburg
Total For County
Guilford
43.20
NC-Olt-007-OIA
Kimrey Jr., Ervin M.
Kinirey Jr., Ervin M.
Oran e
36002'22"
79014'34"
5.60
Herndon
NC -Olt -007-0113
Kfinrey Jr., Ervin M.
Kiinrey Jr., Ervin M.
Orange
36'02'19"
791434"
13.80
llerndon
NC -OR -007-021
Kinn-e Jr., Ervin M.
Kinirey Jr., Ervin M.
Orange
36002118"
79014'39"
18.60
Herndon
NC -OR -022-01
roust, James D
Orange
35'58'28"
79015'09"
16.00
Herndon
NC -OR -022-02
Foust, James D
Orange
35'58'18"
79'15'21"
42.00
Geor eville
NC -OR -022-03 t
---Foust, James D
Orange
35058'09"
79015'12"
15.00
Geor eville
Page 6 of 8

ATTACHMENT 13 - Approved Laud Application Sites
Permit Number: `VQ0000.520 Version: 2.3
City of Burlington
Citv of Burlington Residuals Land Application ProSram
Certification Date: 01/06/2012
Field/Zone Id
Owner
Lessee
County
Latitude
Longitude
Net Acreage
Donuuant Soil Series
NC -OR -022-04
Foust, James D
Orange
35°58'07"
79°15'21"
12.00
Georgeville
NC -OR -064-01
Thompson, James C
Orange
35058'43"
79014'56"
31.70
Georgeville
NC-OR-064-03�
Thompson, James C
Orange
35058'58"
79°14'48"
14.10
Georgeville
NC -OR -064-041
Thompson, James C
Orange
35058'58" 1
79014'38"
24.80
Georgeville
NC -OR -064-05
Thompson, James C
Orange
35059'19"
79014'28"
17.50
Georgeville
NC -OR -064-06
Thompson, James C
Orange
35059'05"
79014'26"
11.50
Georgeville
NC -OR -064-07
Thompson, James C
Orange
35°59'05"
79014'26"
23.00
Georgeville
NC -Olt -064-08
Thompson, James C
Orange
3505843"
79014'26"
29.20
Georgeville
NC -OR -064-10
Thompson, James C
Orange
35058'30"
79014'41"
5.00
Georgeville
NC -OR -064-11
Thompson, James C
Orange
35°59'06"
7914'02"
11.70
Herndon
NC -Olt -064-12
Thompson, James C
Orange
35°58'54"
79°14'08"
21.00
Georgeville
NC -OR -064-13
Thom son, James C
Thompson, James C.
Orange
35°59'48"
79014'28"
39.60
Georgeville
NC -OR -079-01
Sykes, Jeff
Orange
35°59'19"
79°13'21"
8.00
Georgeville
NC -OR -079-02
Sykes, Jeff
Orange
3505948"
79013'08"
30.00
Georgeville
NC -OR -079-03
Sykes, Jeff
Orange
35059'41"
79013'13"
23.20
1Ierndon
NC -OR -079-04
Sykes, Jeff
Orange
35°59'31"
79013'13"
12.50
Ilemdon
NC -Olt -079-05
Sykes, Jeff
Orange
35059'33"
79012'59"
28.00
Georgeville
NC -Olt -079-06
Sykes, Jeff
Orange
36°00'31"
79014'08"
10.30
IIerndon
Total For County
Orange
464.10
NC -RD -O15-01
Brown, Frank
Moore, Brad
Randolph
35°53'51"
79°38'12"
11.10
Sedgefield
NC -RD -015-02
Brown, Prank
Moore, Brad
Randolph
35°53'55"
79°38'14"
.60
Ilelena
NC -RD -015-03
Brown, Frank
Moore, Brad
Randolph
35°53'54"
79°38'18"
2.00
Helena
NC -RD -015-04
Brown, Frank
Moore, Brad
Randolph
35°53'48"
7938'33"
11.50
Helena
NC -RD -015-05
Blakley, Dexter
Moore, Brad
Randol h
35°53'33"
79°37'33"
14.50
Enon
NC -RD -015-06
Blakley, Dexter
Moore, Brad
Randolph
35°53'20"
79°37'31"
2.00
Li num
NC -RD -015-07
Blakley, Dexter
Moore, Brad
Randolph
35°53'12"
79°37'33"
14.00
Li num
NC -RD -015-08
Blakley, Dexter
Moore, Brad
Randolph
35°53'10"
79°34'19"
13.50
Georgeville
NC -RD -015-09
Moore, Thomas
Moore, Brad
Randolph
35°53'09"
79°34'19"
35.50
Georgeville
NC -RD -U15-10
Moore, John F
Randol h
35°53'19"
79°34'12"
11.80
Georgeville
NC -RD -016-01
Blakley, Ernest Clifford
Randolph
35°53'50"
79°38'01"
23.80
Li num
NC -RD -016-02
Blakley, Ernest Clifford
Randolph
35°53'47"
79037'54"
1.60
Li num
NC -IW -016-03
Blakley, Ernest Clifford
Randolph
35°54'04"
79°37'40"
2.00
Melena
NC -IW -016-04
Blakley, Ernest Clifford
Randolph
35°54'01"
79°37'30"
13.20
Helena
NC -RD -016-05
Blakley, Ernest Clifford
Randolph
35°53'50"
79°37'29"
6.20
Helena
NC=ltll-016-06
Blakley, Ernest Clifford
Randol h35°53'41"
79°3732"
22.00
Helena
Page 7 of 8

AT I'ACIMIENT B - Approved Laud Application Sites
Permit Number: WQ0000520 Version: 2.3
City of Burlington
Cite of Burlington Residuals Laud Application Program
Certification Date: 01/06/2012
Field/Zone Id Owner
Lessee County Latitude Longitude Net Acreage Dominant Soil Series
NC -RD -016-07 Blakley, Ernest Clitford
Randolph 35°53'05" 79°37134" 13.50 Iredell
TOM For County
Randolph 198.80
Total
4,152.20
I 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 properly. Note that the I00 -loot setback between wells and the land application area shall still be stet.
2 reduced setback front a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 Leet
of (he residence owned by George and Carolyn Turner (i.e., indicated by the label "##" on the approved setback tial)), regardless of whether a surface or a
subsurface application method is used.
3A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet
of the residence owned by Joe Rice (i.e., indicated by the label "SWAA-Rice" oat the approved setback map), regardless of whether a surface or a subsurface
application method is used.
4A reduced setback front a residence under separate ownership has been approved for (his land application site. Residuals may be land applied within 100 feet
of (lie residence owned by William and Brenda Badley (i.e., indicated by the label "SWAA-W. I ladley" on the approved setback trial)), regardless of whether it
surface or a subsurface application method is used.
`A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet
of the residence owned by Howard and Lorrie Kernodle (i.e., indicated by the label "SWAA-A" on the approved setback map), regardless of wliclhcr a surface
or a subsurface application method is used.
6A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet
of the residence owned by David 11. Deatherage (i.e., indicated by the label "SWAA-B" on file approved setback map), regardless of whether a surface or a
subsurface application method is used.
7A reduced setback front a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet
of the residence owned by Francis T. Austin (i.e., indicated by the label "SWAA-Austin" oil the approved setback map), regardless of whether a surface or a
subsurface application method is used.
RA reduced setback from a residence under separate ownership has been approved fur this land application site. Residuals may be land applied within 100 feet
of the residence owned by Bobby Britt (i.e., indicated by the label "SWAA-C" on the approved setback map), regardless of whether a surface or a subsurface
application method is used.
°A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet
of the residence owned by John and Dorothy McKinney (i.e., indicated by the label "SWAA-B" on the approved setback Wrap), regardless of whether a surface
ora subsurface application method is used.
10A reduced setback front it residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet
of the residence owned by Donnie Wimbish (i.e., indicated by the label "SWAA-A" on the approved setback map), regardless of whelher a surface or a
subsurface application method is used.
11A reduced setback front a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feel
of the residence owned by Stacy and Kathy Price (i.e., indicated by the label "SWAA-D" on the approved setback map), regardless of whether a surface or a
subsurface application method is used.
Page 8 of 8

�� W)
SYNAGR
APPLICATION AREA MAP ® A Residuals Management Company
— PROPERTY LINE
— — • — — STREAM
—•—•—•— - DRAIN
�r POND
— FENCE
' = J STORAGE AREA
Total See Summary Net Acres See Summary I`
(=To APPLICATION AREA - - - - - - - - - • PRIVATE ROAD
is HOUSE�r� FORESTED AREA
OUTBUILDING �UNSUITABLE
QS WELL SUITABLE FOR
O SOIL DESCRIPTION INCORPORATION
(8-1?% SLOP=-',

II. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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;
[J] A re -defined compliance boundary is needed for field(s) ID: !SL'--Av,— it—' — k
(Please include the rationale for the requested re -location of the compliance boundary and attach a map
showing the newly proposed compliance boundary to this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
[3"'1 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, alternatives for waier supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name:
Landowner address
City: rlr< mo eG State: N L Zip: /.3
Phone: 33(n 3 "i
Signature: � 7 ct..t Date:`
NORTH CAROLINA, A .ICOLIA IX," c COUNTY
nn:'...
I, the undersigned Notary Public do hereby certify that � t r,a. � . K`8'YLo A,�
personally appeared before me this day and acknowledged the due execution of the forgoingiinstrument.
WITNESS m_v hand and official seal this the
day of (1Ct_u_ , 20 1 1
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
❑ I certify that 1 have read this Agreement and do Hereby agree to abide by the stipulations and restrictions as
specified herein.
Lessee/operator name:
Lessee/operator address:
City:
Phone:
Signature:
State:
Zip:
Date:
Permittee's Certification:
certify that I have read this Aereement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
Signing official name: j��iiG. ti s I�l L�iC r
Signature: Date:6:71Z �4
*** END OF FORM: LORA ***
FORM: LO n A 09(140 i Pace of 3 Attachment Order ?-c

II. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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
ne y -established compliance boundary. Please mark one of the following;
Are -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 this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
I certify that I am a deeded landowner -of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attorney or other legal delegation, to make decisions regarding the
use of the land application site(s) on behalf of the deeded landowners. I certify that the above -referenced land
application site(s) are not included in any waste disposal contract or agreement with another municipality,
contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement, understand the
stipulations, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified 'herein.
Landowner name: !Seo r ac. L . arid 6z ev !k2 'R, ter.« n e r
Landowner address: e230 / Sarrlz,]�
City: A6 e Lbol e- State: A/C- Zip:
Phone:
Signature: Date:
NORTH CAROLINA, 1 "� COUNTY
,�,�
GWL'1 i— ('��"""""""i" TLUUVt=4,
I, the undersigned Notary Public do hereby certify that �
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the t b
day of MQ„ ►4, 120 1
Signature and seal: *Lk�11-1 6t4m
My commission expires: t p.
Lessee's/Operator's Certification:
(� I certify that r have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein. (�
Lessee/operator name: ,idY1�S rA- (K Bra *v , Xe:.
Lessee/operator address: 93:3*- n
BAYt t' gi �J
f .
City: /1e -,&%#4A— State: N G Zip: % 30
Phone:
Signature: Date:
Permittee's Certi►cation:
,,,�certify that 1 have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
Signing official name: �lit��r Ele/2:(4 �
Signature: td Date: 7,/l,
*** END OF FORM: LORA ***
FOP..1\I: LORA 090401 Pao; 3 o;'_ AtlaClmlel]t Order ,-c

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 lveb site at: http:11h2o. enr..state. nc. us/lau/main. 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: C-1 !;!°�► G� ��;.k e S.." ^A
Complete mailing address of applicant:
City:
State: zip: 'i l.6 - 1 a
Telephone number: (( 3IL, ) <riG -- lv13`� Facsimile number:
E-mail address: S t k t4 c!,,r e a , 6'" , n` , as
hereinafter referred to as the Permittee, to land apply residuals within feet (i.e., cannot be Iess
than 100 feet) of the residence or place of public assembly locatedatthe following:
JLocation�adddres`s of property: � saf-'I f JG 2.0,
"City: /''l GV Q n a State: rG 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,
Viv
n 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
J
L/ Signature:
rd/
FORM: SWAA 070807 Page 1 of l
Date
Attachment Order _ d

j C3 i.- "1
s
Nu
LO., f%
W
R
A �,w
J� ' 1
0
. d
LA M3
j
vp
Owner(s) ���Ql�� A. l,J.f
� `� � I« - /�,i'n - 1 �� -
- Scale: 1"
660' Field #--1423
= LV
. > STREAM
T APPLICATION
Total Acres
(see summary) Net Acres
(see summary)
> DRAIN
CID AREA
Q SOIL DESCRIPTION
CDSURFACE WA'rF..R
® HOUSE
-- — -- -- -- - PRIVA'T'E ROAD
3E-1�-3E- FENCE
U OUTBUILDING�
FORES•IBD
UNSUITABLE ®
SUITABLE FOR
INCORPORATION,
0 WELL
AREA
PROPER•1'Y LINE
8-120.b SLOPE

11. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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 marl: one of the following:
A re -defined compliance boundary is needed for field(s) ID: f1� II;J✓� "4� 'i
(Please include the rationale for the requested re -location of the compliance boundary and attach a map
showing the newly proposed compliance boundary to this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
I certify that I am a deeded landowner of the above -ref renced 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 attornev 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, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to theittee to land apply Presiduals to the land application site(s) as specified herein.
Landowner name: � 6 �`I Z ! er — MIR to
*** END OF FORM: LORA ***
FORM: LOAD. 090401 Paee 3 of 3 Attachment Order =-c
Landowner address: 1 1w F M G1C l l
4/
City: +C, r O State:
r7
�� Zip: �Z l
Phone:
Signature:
Date:
NORTH CAROLINA, /V (fl—f
COUNTY
o k f A t --)-4 A
I, the undersigned Notary Public do hereby certifj, that
A • U-te.
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
i
day of 1,�o V t �,
.20 i 0
Signature and seal:
JAMES R. BLACKWELL
My commission expires
1401ARY PUB=
CASWELL COUNTY
Lessee's/Operator's Certification:
MY COMMISSIQN EXPIRES ��r`
❑ 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:
Lessee/operator address:
City: State:
Zip:
Phone:
Signature:
Date:
Permi s Certification:
I certify that I have read this Agreement and do hereby
agree to abide by the stipulations and restrictions as
specified herein.
Sicnin_ official name: !4414 e—���
Signature: ��
Date: &Z-2-7/le
*** END OF FORM: LORA ***
FORM: LOAD. 090401 Paee 3 of 3 Attachment Order =-c

owner � :1 l lrldl F� � 1
r
STREAM
DRAIN
SURMCE WATER
----- ----�---• PROPERTY LINE
r�-
t
(AIA s� t
0?— ;r y
r
V
Scale: 1"
Field #
APPLICATION
Total Acres
< j•..:.< ,'! yNet Acres
ARCA
0 SOIL DESCRIPTION
r
® I[OUSE
— — — — — - PRIVATE ROAD
❑ OUTBUILDING
CDAREA
FORI:STEDSUITABLE
UNSUII'�WLE l -t
-I -I-1
ICOR
INCORPORATION,
1W LL
�CI�
8-12.4, SLOPE

Il. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However. 15A NCAC
02T .0105(h) allows the compliance boundan, 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: Aro, —IL' "3
(Please include the rationale for the requested re -location of the compliance boundary and attach a map
showing the newly proposed compliance boundary to this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attornev 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, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
Qrant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name: CL (,T'-1CS (9n � 0 le �
Landowner address: 53-3 g.3 a e -z S, r r_
City: Sy) ow CGA YYn !Q State: t"J Cr Zip: 0
Phone: 3 3 (o — 3 -7 (,-, - �3 +3 0
Signature: ✓ C,�' r": i% Date: ®1 -C^q f 'I��
NORTH CAROLINA, I --t C14 La- COUNTY
I, undersigned Notary Public do hereby certify that e� OGy �'stoal ! - �iC1 �1��• _
personaliy appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the L+
day of �3a�n� a�r�-t, _ 20 6 F
SiCnature and seal: �sf, �� �h,E ►�' ' } ' r
�.y
a1
My commission expires: ,4 -- -7 - --Zyt Li
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. tt
Lessee/operator name: C 14 t- e\ L ri ca 4 e
_ t
Lesseeioperator address: 27 3 ._E -P-4-k e 5 Tu i F?d
City: �r'1a G Yvly� State: ►� Zip: _- . i'3 G
Phone: (C — 3776. - 3 L!3
Sienature: Date: �'-�12-
Permittee's
Certification:
I certiN that I have read this Agreement and do hereby a;;ree to abide by the stipulations and restrictions as
specified herein. // 1 /
Signing official name: 15(/1u1117e_ ��G7G(i1C�
Siunature: _ ,�_.c. i.�i� ^' Date: 62 LZZ///
END OF FORM: LORA t f
I-n1"Al.:1_<. �: �A 00040 7 Pace ? of : Attacimient Order c

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 02-07)
(THIS FORM MA I' 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 weh site at:httn://h2o.env.state.nc.us/lau/nrain.lutrtl
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.1 108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name:
Complete mailing address of applicant:
Y, F_,) -3 t)
City: GLIY'State: NC Zip: o�� �� (� — 1'4)516 L
Telephone number:JS — W 1 S1, Facsimile number: to E 2 �1
E-mail address: 1A C:v\t,- MN C i. hu(I I (1C . V�
hereinafter referred to as the Permittee, to land apply residuals within 106 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: ', 2`% t' J �' '•- "
City: A f'.h: i. State: ;V_ 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 certiN 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 gram permission to the Permittee to land apply residuals to land
application site(s) as specified herein.
Property owner name: _ •' -
-----
Signature: Date:
FORM: SWAA 02-0? PaL: I of'] 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 02-07)
(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.
Forntore information, visit our web site at:httn:11h?o.ennstate.tic.us/latu'ntain.hnnl
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 A 108, 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:
Complete mailing address of applicant: PON
City: Ut'i lt'1�y
1Ut'�
State:
Nr Zip:
X10 1 �,
- 1 J �
Telephone number:
(ti 1�)
!S'7()— vol j k
Facsimile number: ( I? L
) J -1G
— (0 V7)12)
E-mail address:
hereinafter referred to as the Permittee, to land apply residuals within 16C 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:
City: ' s CA. ►1 State: 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 lone 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.
r
1 certifjl 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:
Si«nature: Date:
FORM: SW.gA 02-07 Pa«r i of 1 Attachment Order ',-d

0
APPLICATION AREA MAP
0))
SYNAGRO
A Residuals Management Company
9
R
_ i 1
1.'
1
Owner R"ss°�,', 1 �L�1d !•" lScafe: 1" = 660' Field #
— PROPERTY LINE Total Acres See Summary Net Acres See Summary
— — — STREAM
—•—•—•— -DRAIN
O POND
FENCE
STORAGE AREA
APPLICATION AREA
® HOUSE
D OUTBUILDING
QS WELL
SOIL DESCRIPTION
--- - - - - -- •PRIVATE ROAD
C)
FORESTED AREA
UNSUITABLE
FOR
QmSUITABLE
INCORPORATION
(£-i3°ib SLOPE:

APPLICATION AREA NEAP
SYNAGRO
A Residuals Management Company
Owner P-u„6st II �% P; it-' ( I,14:f AN'- 1 L) Scale: 1 660' Field
PROPERTY LINE Total Acres See Summary Net Acres See Summary
STREAM APPLICATION AREA – – – – – – – – – - PRIVATE ROAD
— - — - — - DRAIN V HOUSE � FORESTED AREA
OPOND 12 OUTBUILDING Qm� UNSUITABLE
FENCE '0 WELL SUITABLE FOP
STORAGE ARES. C; SOIL DESCRIPTION QM INCORPORATJON
G) (&-12'X. SLOPE)

11. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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;
Q A re -defined compliance boundary is needed for f eld(s) ID: • Ate' ILP
(Please include the rationale for the requested re -location of the compliance boundary and attach a map
showing the newly proposed compliance boundary to this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
II1. RESTRICTIONS:
Landowner's Certification:
® I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power'of attorney or other legal delegation, to make decisions regarding the
use of the land application site(s) on behalf of the deeded landowners. l 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, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name: (_ L. aT-kS
Landowner address: "j : 7'�3 S',
City: SYlouZ CG,ryn �Q ' `_ State: R: C, Zip: 2734
Phone: 3 3 c.,- 3 L, r c�27 +3
..� �l
Signature: P/ � �`: Date: 0 V -_ _i
i
NORTH CAROLINA. , 5 Lt w%.ca 0 LDL_ COUNTY
I, •u:e undersigned Notary Public do hereby certify that r' 1 C" 4=5rx1 L_ $ aLAts %_4 _
t
personalty appeared before me this day and acknowledged the due execution of the forgoing• instrument.
WITNESS my hand and official seal this the `
day of ��ay�u ur -+ 20 1 C
Signature and seal: ��„�, �E.�. (1- 4�
My commission expires: a� ” 7- -_tfi
Lessee's/Operator's Certification:
(1 I certifi, that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
Lessee/operator name: e 4 r t5 C Yi L - it -1t t1�� e u
i
Lessee/operator address: S/27-73 t�-tC- � tz J F u r r- PUt
City: S X10 ..J E_ t� State: t Zip:
Phone: _313 (c _ 37G1 ' 4 L,
Signature: r� i 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:y I�Gt✓�� ���TGI�e�
Siunature. ��.c` Vii.•_ �� Date: Cep /Z 7/&
_ —T
END OF FORM: LOAA
FOR NI: LOAN 090401 l a__ --, of = Attachment Order 3-c

11. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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;
,Q A re -defined compliance boundary is needed for field(s) ID: !�L" *&-
(Please include the rationale for the requested re -location of the compliance boundary and attach a map
showing die newly proposed compliance boundary to this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
,Q I certify that I am a deeded landoAmer 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, alternatives for water supply wells inside the compliance boundary. and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name: �► ��%�.� �� //i9%�� i'
' Landowner address: 9 l
City: 0W C 447."r
State: /4/, /`, Zip: 2 73 4 5
Phone:
Signature: %rte,- -.4e Date: c OCC /C
NORTH CAROLINA, A to OAA V�t e-- COUNTY
I, the undersigned Notary Public do hereby certify that
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNIESS my hand and official seal this the v s e �A 4crAL" _-�_ y
da •; of t.e ,, )[,� _. Y 20 1 0 1
Signature and seal:
My commission expires: - ;�_l — 2 r. 1 �-
Lessee's/Operator's Certification:
j I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
i
Lesseeioperator name:L%
Lessee/operator address: 5 7 f;` �� l _>'� L' •=G/'/' 1 1__
City: 74'i'Cl' I .�17f� State:
Zip: ? 71—, 4- - l
Phone: 36' ">' 7th G
Signature:`Date
Permittee's Certification:
certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
SiLmine official name: .S 0erm �-
SiLmature:
*** END OF FORM: LOAA * **
Date: LZ2 7�1.
FORM: LO k-% 090401 Pay_: o -:, _'Maclunent Order

��1111,
SYNAGRO
APPLICATION AREA MAP
A Residuals Management Company
Owner nil ► -'� Sa� 'r�•- jt -s; - Scale: 1" = 660' Field # r
— PROPERTY LINE Total Acres See Summary Net Acres See Summary
— • • — • • — • — STREAM 0=:0 APPLICATION AREA — — — — — — — — — - PRIVATE ROAD
— • — • — • — — DRAIN V HOUSE FORESTED AREA
OPOND
❑ OUTBUILDING
UNSUITABLE
FENCE
WELL
SUITABLE FOR
f�1INCORPORATION
STORAGE AREA
p SOIL DESr—RIPTION
���'
(E -1210k SLOPE)

a
APPLICATION AREA MAP
SYNAGB%,0
A Residuals Management Company
V.7
i 4
T t
A
5L)
14.
S�
A
L);�00 hDs-tek
Owner A?P1-! L GQ Scale: 1" = 660' Field # 1,2 LL
PROPERTY LINE Total Acres See Summary Net Acres See Summary
STREAM 0=�o APPLICATION AREA - - - - - - - - - - PRIVATE ROAD
— - — - — - DRAIN R. HOUSE FORESTED AREA
OPOND E] OUTBUILDING UNSUITABLE
FENCE Qj WELL SUITABLE FOR
STORAGE AREA, p SOIL DESCRIPTION INCORPORATION
SLOR=',

'i
11. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
I 5 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 %yell 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:
0 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 this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attorney or other legal delegation. to make decisions regarding the
use of the land application site(s) on behalf of the deeded landowners. I certify that the above -referenced land
application site(s) are not included in any waste disposal contract or agreement with another municipality.
contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement, understand the
stipulations, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name:
Landowner address: [ [ P oat e 4rJ
City: &Pnt �t �-c� State: /tf • !! Zip: A7,A/ 7
Phone:_ `—� — % b — �`+[:o C — 8% 9r 0
Signatur Date:
i
' NORTH CAROLINA, �. A4 ��` �` COUNTY
I, the undersigned Notary Public do hereby certify that �t'�^s� QJc ii
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sea) this the "t
day of ! 20
Signature and seal: ` JAMES R, BLAC7QN
My commission expires: — S— �S CASWELL CO
Lessee's/Operator's Certification: MY COMMISSION EXPI=E Qr= NORTH CARD
❑ 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:
Lessee/operator address:
City: State: Zip:
Phone:
Sit_mature: Date:
Perm eels Certification:
I certify that I have read this Agreement and do herebv agree to abide by the stipulations and restrictions as
specified herein. ! /
Sianing, official n e:
Signature: Date: d-7111,
END
END OF FORA -I: LOAM
FORiM. _O :.. 00O401, ''ae . o; . Anaclvnent Orde.

State of North Carolina Ilk. Swat, -A
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:hrtv://h2o.enr.state.nc.us/1au/main.html
ti
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: �i��1 ��u.-� ��t� t� t -i
Complete mailing address of applicant: P C,
City: �'�.Lr�: -�,,,s State: Zip: ? :alts—tZ5
Telephone number: (-171W Facsimile number: ('PKP )•a�G"urt `'1
E-mail address:
hereinafter referred to as the Permittee, to land apply residuals within i or— 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: t (�.�. u F:_,� -
City: � .t'' a� �« State: 4C- 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,
gi
en 30 calendar days in advance, modifies or cancels this Agreement.
2 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, 1 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 fowner name: � � � • ..
��
Date:
FORM: SWAA 070807 Paee 1 of I Attachment Order 3-d

State of North Carolina 5`"' A "
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAINTR AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 070807)
(THIS FORMMAYBE 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: htty: //14.20. enr. state. nc. us/lau/main. 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.1 108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
Applicant's name:
v
Complete mailing address of applicant: 00 r o-_ t� 5i3
City: EtiState: Zip: W+—
Telephone number: (rites, )` �'1Cr �,t3�3 Facsimile number:
E-mail address: S c~�,c h "..►'.�' C_► .� rl ► n : ^ . n` , ;x S
hereinafter referred to as the Permittee, to land apply residuals within feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
Location address ofproperty: -1+ `� 0 t a w v ► .
City: ��.rt rs State: µ Zip: _ 214
This Agreement shall remain in effect for the length of the Division of Water QuaIity'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,
;ivencalendar 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 certit, 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.;pecified herein.
Property ownern4e:
Signature:
Date: 0, Eta I
FORM: SWAA 070807 Page 1 of 1 Attachment Order ;-d

D
APPLICATION AREA MAP
4
~��i. t' •��,��� % / J'"✓iii j\ �..\. C �'i
05%1')
SY NAGPO
A Resia�zalt Managanent Cnmpmt)
��� '- •:�� fit!/' ~��.ti. 'L'
•� r
f qq
1
/• t
Owner Scale: 1" _ Field # I .
Total Acresiu:< Net Acres
— — — — — - PRIVATE ROAI)
FORESTED AREA
UNSUITABLE
SUITABLE FOR
INCORPORATION,
8-120/'o SLOPE
STREAM
<
APPLICATION AREA
—�
DRAIN
HOUSE
Ci:)
SURFACE WATER
❑
OUTBUILDING
N ;:
FENCE
WELL
STORAGE AREA
SOIL DESCRIPTION
PROPERTY LINE
— — — — — - PRIVATE ROAI)
FORESTED AREA
UNSUITABLE
SUITABLE FOR
INCORPORATION,
8-120/'o SLOPE

11. ALTERNATIVES FOR WATER SUPPLY NVELLS INSIDE THE COMPLIANCE BOUNDARY:
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 this agreement prior to obtaining any signatures on
this agreement)
A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
In
60
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 outer 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 an}, 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,
grant permit
Landowner
Landowner
City: '.0 State: /4 C.- Zip:
Phone: 3 36 - 239 115?,
Signature: Date:
NORTH CAROLINA,
I, the undersigned Notary Public do hereby certify that
COUNTY
z7US
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the `'� tt M
day of U .20
Signature and seal: R; ROSE
My commission expires:
Q D ALAN
NNull
Lessee's/Operator's Certification: My Commission
❑ 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: _
Lessee/operator address:
Citv:
Phone:
Signature:
State:
Zip:
Date:
Permittee's Certification:
,['I certifil that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
snecified herein.
Signing official name:
Signature: i
** ` END OF FORM: LOAA *�
Date:
FORM: LOA.-'� 090401 Pas= = o ?- Attachment Orde- ',-I-

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 02-07)
(THIS FORM ATA F 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: hum-11h2o.enr. state.nc.us/lau/main.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.
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.1 108(b)(2)(habitable residences)
The undersigned property owner hereby permit permit
Applicant's name:1 ". �t , _ 0"' _ ` _) ih r t
Complete mailing address of applicant: 0. O 7
City: ' ; w��'i.114 State: _ � Zip: a q'! 16— i 15
Telephone number: (331e) Facsimile number: (3� ; )
E-mail address: f r� L� a e'�+C'*� Lor%
J
hereinafter referred to as the Permittee, to land apply residuals within feet (i.e.. cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
` I
Location address of property: ! apia e�_17d M ej k Q 4 0 1 . h cl
-' f AL. C Zi x,17
City: b tAr + el fa D In State: p: ��;
This Agreement sliall 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.
�giv n 30 calendar days in advance, modifies or cancels this Agreement.
I certif}r 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:/�'_.�1" y 77'- L,� i�l i..,.
Signature: '-- i'� J Date:
FORM: S'W*AA 02-0"' Page 1 of 1 Attachment Order 3-d

ADM TCA T'TC)1\T APFA MAP
l iL 1 Yi va a a r v+
0W�
SYN.AGR
n ifestauais jnanagemeni L,ompany
41 r_i
ye
s .a
C. QT y 1 Su s,A
��,� ��� tip •--"'��� `�I � rJ�
Owner �P_ k? `�
�'.tc ' �`' " ' Scale: 'l" = 660'
Field #
,
— — PROPERTY LINE Total Acres See Summary
Net Acres See Summary
— • - — • • — — STREAM
APPLICATION AREA
– – – – – – – – –
• PRIVATE ROAD
— • — • — • — • – DRAIN
■ HOUSE
C3
FORESTED AREA
O POND
❑ OUTBUILDING
UNSUITABLE
o— FENCE fi WELL
SUITABLE FOP.
INCORPORATION
O STORAGE AREA
p SOC_ DESCRIPTION
(&-12°io SLOPE)

SYNAGRO
APPLICATION AREA MAP A Residuals Management Company
1/17)
-0-33
uy'l 0 Co I D&E.. ter,
Li
V t
L
OX
r)L
, '- AA .4
M -";: - I
Owner 7- Scale: 1" = 660' Field #
PROPERTY LINE Total Acres See Summary Net Acres see Summary
STREAM APPLICATION AREA - - - - - - - - -- PRIVATE ROAD
- - - - - - DRAIN C HOUSE C) FORESTED AREA
G) POND 0 OUTBUILDING UNSUITABLE
QB>
FENCE fCi WELL SUITABLE FOR
INCORPORATION*STORAGE AREA Ci SOIL DESCRIPTION
x- 12% SLOP=j

II. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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
sup/ly well is situated outside of the compliance boundary provided the groundwater standards can be met at the
ne ly-established compliance boundary. Please mark one of the fallowing;
A re -defined compliance boundary is needed for field(s) ID: 1 :: - Gs- 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 this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attorney or other legal delegation, to make decisions regarding the
use of the land application site(s) on behalf of the deeded landowners. I certify that the above -referenced land
application site(s) are not included in any waste disposal contract or agreement with another municipality,
contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement, understand the
stipulations, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name:
Landowner address
City: 60P%k Ny�-�c9iJ State: A) • Zip: A7J,/1
Phone: _S _ r% 10 0 0 90
Signatur Date:
NORTH CAROLINA, �. �� w� �� COUNTY
`
I, the undersigned Notary Public do hereby certify that ,rpv4L (�)e it
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
day of MA • 20
Signature and seal:` JAMES R. BLACKWELL
My commission expires: S- l
CASWELL COUNTY
rm NORTH GARQ INA
Lessee's/Operator's Certification: MY COMMISSION EXPIRES
❑ I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
tr
specified herein.
Lessee/operator name:
Lessee/operator address:
City: State: Zip:
Phone:
Signature: Date:
Perm' ee,s Certification:
1 certify that .I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
Signing official n
Signature: ,- ���-- Date: ld, 7
END OF FORM: LORA * -Y
FORlvl: LORA 090401 Pa :' er _ Attacinnent Order ;-c

State of North Carolina �wtlpl —A
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WAITER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 02-07)
(THIS FORM AM )-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 iveb site ac: htto://h2o.enr.state.nc.usliauintain.lum!
INSTRUCTIONS TO THE APPLICANT:
A. Attachment Form:
✓ Do not submit this attachment form for review without its corresponding residuals program
application form (FOR I: 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 A 108, 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.1 108(b)(2)(habitable residences)
The undersigned property owner hereby permits:
r~�`
Applicant's name: L� l l n4 t _>• 1�/, kr g
Complete mailing address of applicant: "15 NIL
City: f'_ IX4'>.4 Lo' -1 State: Zip: DI X16 — X 3
Telephones number: ( z� ) -t � tie a '� Facsimile number: (` 3L ) a510 — U -03,::f
E-mail address: 4_SFTL*r- r v hug' hqt.� 11i LL,5
hereinafter referred to as the Permittee, to land apply residuals within feet (i.e.. cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
cation address of property: L(� c� � Lel tS OrtrF
� 1 State:
� �✓ Al.Jt/. J � . Zip:
G
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,
V
30 calendar days in advance, modifies or cancels this Agreement.
2 l 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.
,4roperty owner name: L �x� of F �-✓; �-�( �� ,
t/Signature'L2t,; Date:
FORM: SVAI.4A 02-07 Page I of I Attachment Order 3-d

State of North Carolina $OA,4` G
Department of Environment and Natural Resources
Division of Water Quality
SETBACK WA117ER AGREEMENT ATTACHMENT
For Land Application of Residual Solids (FORM: SWAA 02-07)
(THIS FORM AL1 I' 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.
Formote information, visit our taeb site at:httn:11h2o.ennstate.nC.us/lauimartr.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.1 108(b)(2)(habitabie residences)
The undersigned property owner hereby permits:
Applicant's name: C� r 'f 'ii Lt �-� I`.) Jnn1^ �; ti` g=4—o�
Complete mailing address of applicant: P. G' - :'o s,
City: �� w r�, i rAis State: Zip: �i a-1 LP
Telephone number: (3 �(y) S r) O •— Lv i � L Facsimile number: (� ,ij,
E-mail address: S �A t- {��Q ' �� Lt �t Ic! . rn,.- . U�
hereinafter referred to as the Permittee, to land apply residuals within X60 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
Location addressQofxropert): �,r�� \ i Niy-1 �
City:te/t�. ,�•.�� State: ij r Zip: j
This Agreement shall remain in effect for the Iength 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 onl1• 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,
givZcerifi,
calendar days in advance, modifies or cancels this Agreement.
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 own natter u
Sienature:�'
For\A1: SWAA 02-07 U I'af�: 1
Date:
Attachment Order 3-d

State of North Carolina
SK;Ak.--C,
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 MAI' 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 it?fat•ination, visit our web site at: hiti)://h3o.enr.state.nc•.tts/lauirnaiia.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.
B. Prepare a separate attachment form for each property from which it 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 1 SA NCAC 2T.1 108(b)(2)(habitable residences)
The undersigned nro-erty owner her,-- '^rmits:
Applicant's name:
Complete mailing address of applicant:
{ t
City: �7 :' l n c; TJ r -N State: 4 v C . Zip: '-p �� 1t.01
Telephone number: (736) i1 " LP 1 3tb number: (_Z31,.) . 5"76 7S=
1 ,
E-mail address: �` t A t' . —G= b u -r 4� Ot �i-n • ''�G ii.
hereinafter referred to as the Permittee, to land apply residuals within EOE} feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
J/t:7
Location address of property: 6'15 a r11 U F_1 K ►0\r, •t' ZOCG .
'City: _e \ n G In State: 1 y c Zip: 1
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.
dI 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. 1 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:
i.
i_nature: _ _ �-
Date, 1- - )
FORM: SWAG 07080-1 I�Iaet ! of I Attachment Order 3-d

D
FWIW _ ralllili�111111 i!!11111 111 11111111 111
,
SYNAGR
A Residuals Management Company
^•..,� Vj o o Q S
t-,)uoos
Owner J �r<.'.�r' �� ��r.f.. Scale: 1" = 660' Field # t.
PROPERTY LINE Total Acres See Summary Net Acres See Summary
— • • — • • — — STREAM
-------- - DRAIN
E POND
If 1! FENCE
r y } STORAGE AREA
APPLICATION AREA
Q HOUSE
M OUTBUILDING
0 WELL
O SOIL. DESCRIPTION
---- - - - - -• PRIVATE ROAD
FORESTED
mUNSUiTABLE
."
SUITABLE • -
INCORPORATION
SLOPE)

100, Ala t>
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 02-07)
(THIS FORM MA I' 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:httn://h2o.enr•.state.nc.us/lauiinain.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: e 7,;_74Y !.) t 9w�; ,V �9-1d PJ
Complete mailing address of applicant: Pf% �� b >L.I 5z"?-
City: State: Zip:1 LP — 13 S
Telephone number: (r"�`IU a �� — luj D tFacsimile number: ( 31v) 5101— �,z 1�S r -A
E-mail address: _S } `P t r�i.� �i w r 1 i c�;:t d1 to
J
hereinafter referred to as the Permittee, to land apply residuals within 166 feet (i.e., cannot be less
than 100 feet) of the residence or place of public assembly located at the following:
P-'focation address of property: r 5 V �A
✓City; ..l n Cry -d r� State: 1\(. �.. 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 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 certiffil that I have read and
understand this Agreement and do hereby grant permission to the Permittee to land apps), residuals to land
application site(s) as specified herein. S r l4c VL
Property owner name: ���, ���`'� ��''✓` J
1-01-ignature: S �L b� 2411. Date: /
FORA: SIA'.A,A 02-077 Pae: l of 1 Attachment Order 3-d

APPLICATION AREA MAP
SYNAG�O
A Residuals Management Company
L
i
L
�4
Owner R1 A -;4'
Scale: i" = 666' Field # _
NLG - GS _ 11-7 Total Acres See Summary Summary
Net Acres See S
— PROPERTY LINE ry
— • • — • • — • — STREAM OE:i:�o APPLICATION AREA — — — — — — — — — • PRIVATE ROAD
— • — • — • — — DRAIN ® HOUSE FORESTED AREA
O POND ❑ OUTBUILDING
UNSUITABLE
}— FENCE WELL
SUITABLE FOR
• S STORAGE ARES. p SOIL DESCRIPTION* INCORPORATION
(5-12% SLOPE)

II. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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 this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attorney or other legal delegation, to make decisions regarding the
use of the land application site(s) on behalf of the deeded landowners. I certify that the above -referenced land
application site(s) are not included in any waste disposal contract or agreement with another municipality,
contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement, understand the
stipulations, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the PApnittee to land apply residuals to o the land application site(s),gs specified herein.
Landowner name: f l .� ' -. C_
Landowner a dress: E b C�bV 3 r-_ ►.�� �i''r Ind i
City: State: % Zip: eV1--1 X i
Phone: S36.- S 14-44S'7 �56n e_ _ 1- v K)
Signature: O Date:
NORTH CAROLINA, COUNTYtN
I, the undersigned Notary Public do hereby certify thatctR�� ••••t.:;
personally appeared before me this day and acknowledged the due execution of the forgoing inIIru`rl2ent.�Orq
WITNESS my hand and official seal this the
da of 20 I 1 ��.. AUBLIC
Y �• ,r•O .
Signature and seal: V.' . �.•i41
9ti••'•••••••••' �' •`
My commission expires: IFtlttiw o%\�``\
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:
Lessee/operator address:
City:
Phone:
Signature:
State: Zip:
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.
Sighing official name: S k,?K e ale G►�
Date: EG 12 7l/l
*** END OF FORM: LORA ***
FORM: LOAA 090401 Page 3 o Attachment Order =-c

E
��lll1,
SYNAGRO
APPLICATION AREA MAP A Residuals Management Compa? tiT
0- " '
!
Owner ,2L
Scale: 1" = 660'
Fiefd ru'-
— — PROPERTY LINE
Tota! Acres See Summary
Net Acres See Summary
— — — — STREAM
APPLICATION AREA
- - - - - - - - - • PRIVATE ROAD
— • — • — • — • - DRAIN
E HOUSE
C) FORESTED AREA
OPOND
G OUTBUILDING
Qm� UNSUITABLE
— FENCE
WELL
SUITABLE FOP.
S STORAGE_ AP.=_F.
O
r.• SOI! DESCRIPTIOP,,
INCORPORATION
SLOP

p SYNAGPQ
APPLICATION AREA MAP A Residuals Management Company
Owner ��`�'�'� �� ;�} Scale: I"= 660' Field #
PROPERTY LINE Total Acres See Summary Net Acres See Summary
— • — • — STREAM 0=�o APPLICATION AREA - - - - - - - - - • PRIVATE ROAD
— • — • — • — - DRAIN ! HOUSE C) FORESTED AREA
O POND ❑ OUTBUILDING
UNSUITABLE
FENCE 0 WELL SUITABLE FOR
O STORAGE AREA @ SOIL DESCRIPTION! INCORPORATION
(8-120,b SLOPE)

II. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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; tt��
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 this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attorney or other legal delegation, to make decisions regarding the
use of the land application site(s) on behalf of the deeded landowners. I certify that the above -referenced land
application site(s) are not included in any waste disposal contract or agreement with another municipality,
contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement, understand the
stipulations, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name:
Landowner address: n ! * r i ut e n rP sT I J/`
City: l P f C ;:L4State: /,IV C Zip: 3 4 (•�
Phone:
Signature: Date: R - (co
NORTH CAROLINA, COUNTY
I, the undersigned Notary Public do hereby certify that ar.I'A is �, ? Q ►�1 q r
R
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the 1lu 1��
day of A u-1 tk,Z64, , 20 L1
Signature and seal:
My commission expires: ' 3 - 2 S "
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:
Lessee/operator address:
City:
Phone:
Signature:
Permittee's Certification:
State:
Zip:
Date:
-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:
Si_nature: Date
*** END OF FORM: LOAA ***
FORM: LU.ti=. 0904(1; !,aut o Attachment Order 3-c

II. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE -COMPLIANCE BOUNDARY:
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: C.u'3"A_1� &A -
(Please include the rationale for the requested re -location of the compliance boundary and attach a map
showing the newly proposed compliance boundary to this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
1 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, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name:S,o�%^✓C.�i
Landowner address:
City: r �/ State: /[�' �`'� Zip:
Phone: ? -
�� ZG E
Signature:=jam�.0-�^�° Date:
NORTH CAROLINA. lq'%'nAe COUNT'
I. the undersigned Notary Public do hereby certify that -A -y -'s r7 • 1SrC,wR. t•
personally appeared before me this day and acknowledged the due execution of the orgoing ' u+crct
PUBL
WITNESS my hand and official seal this the 7 : ~ P rw hir L COUP
Y COMMISSION EXPIRE
day of _.Ata IA -AC - 20 V1
Signature and seal: l �"-x"' ��I�� '`F' v' • R��
My commission expires: "• ¢;�►;. :;` z:; r,
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:
Lessee/operator address:
City: State: Zip:
Phone:
Signature: Date:
Permittee's Certification:
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:
C"Ar
Date:
�
**� END OF FORNI: LORA
FORT\!: i0 A n 00040.1 P a 2 t ', o Attachment Order 3-c

Il. ALTERNATIVES FOR WATER SUPPLY WELLS INSEDE THE, •COMPLIANCE BOUNDARY:
15A NCAC 02L ,0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC
02T .0105(h) allows the compliance boundan' to be placed closer to the waste disposal area, such that the water
supple well is situated outside of the compliance boundary provided the -groundwater standards can be -met at tha
1, new]y-established compliance boundary. Please marl: one of the following:
A re -defined compliance boundary is needed for field(s) ID: G�'3c�� 611A-4tL�
(Please include the rationale for the requested re -location of the compliance boundary and attach a man
showing the newly proposed compliance boundary to this agreement prior to obtaining any signatures on
this agreement)
❑ A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
-I certify that 1 am a deeded landowner of tha 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 1
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; fir other permitted entity. Furthermore, I certify that I have read this Agreement, understand the
stipulations, alternatives for Avater supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name: _ tf
Landowner address:
r
City: i State: . � •� � C., �v' I(i .t�.� Zip:.
Phone:
Signature: Vii+-�-;� '��.t.=.--�— Date:
NORTH CAROLINA, `�t'�, n,: e COUNTY
n
I, the undersigned Notary Public do hereby cenif<' that .�^'S,C� �� 1 rC" •
personally appeared before me this day and acknowledged the due execution of the orgoing
WITNESS my hand and official seal this the c�•�'�A = Wr-se_
day of .... y ,�.- ��' "COr001SSIOt� E;
- 20 1 L
Signature and seal: }P. FR
`
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 restrici
specified herein.
Lessee/ouerator name:
Lesseeroperator address:
City:
Phone:
Signature:
State:
Zip:
Date:
Pernt.ittee's Certification:
-D-1—cenify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
r
i L /
Si -nine official name:
Si�,
rnature: �i Dace: 2'/+
i• 'r .;�
*x END of FORM: Lo.4_A **q.
Paee3 of- Attachment Orde: -:
,f!

e
'11 ill STNAGFO
APPLICATION AREA, MAP A Reridmalr nfanagentent Combam-
VI
Owner F:.2 �', i-)
/2!
I" _ Field I `T -
Scale: 1
Total
Total
Acres
Net Acres
STREAM
APPLICATION AREA
— — — — — - PRIVATE ROAD
—7
DRAIN
®
HOUSE
FORESTED AREA
CDSURFACE
NVATER
❑
OUTBUILDING
UNSUITABLE
„
FENCE
0\'ELL
S
(�
STORAGE AREA
O
SOIL DESCRIPTION
SUITABLE FOR
INCORPORATION.
PItOPERT�'LIhE
.8-1'-'%. SLOPE

11. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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 fields) 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 this agreement prior to obtaining any signatures on
this agreement)
r A re -defined compliance boundary is not needed for this site.
III. RESTRICTIONS:
Landowner's Certification:
,[ I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attornev 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, alternatives for water supply wells inside the compliance boundary, and restrictions, and do hereby
grant permission to the Permittee to land apply residuals to the land application site(s) as specified herein.
Landowner name: �E V t Nhti,L i s`R e y -Zr,
Landowner address: 1 4L�
City: �S A tl a State: 13+ <- Zip: ~1 j 0 eZ
Phone: 4A 4�
Signature: Date:
NORTH CAROLINA, I AfhAr:►GQ COUNTY
I, the undersigned Notary Public do hereby certify that F �d t u N� k: m r •)(' ,
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the (�► L�
day of
Signature and seal:
My commission expires(:e,1 -1
20 l6
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:
Lesseeioperator address:
City: State: Zip:
Phone:
Signature: Date:
Permittee's Certification:
certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
Signing official name:
�l/LAh
�f�iGtnP�
Signature:
Date
*** ENI) OF FORM: LORA ***
FOP, N` LO.A.A'. 000-10 * Pave?. o" , • Attachment Order ?

e
APPLICATION AREA MAP
SYNAGPQ
A Reridrrali Managemew Company
Owner Q r 7 o Scale: l" = �� %�� I Field #
f f 1 / uC IL. ley
STREAM
DRAIN
SURFACE WATE1
FENCE
CSTORAGE AREA
PROPERTY LINE
Total Acres
PRIVATE ROAD
APPLICATION AREA
FORESTED AREA
HOUSE
❑
OUTBUILDING
SUITABLE FOR
WELL
O
SOIL DESCRIPTION
Net Acres-'
— — — — — -
PRIVATE ROAD
FORESTED AREA
UNSUITABLE
SUITABLE FOR
l�
INCORPORATION:.
8-120/. SLOPE

11. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY:
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; qq
[ A re -defined compliance boundary is needed for fields) 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 this agreement prior to obtaining any signatures on
this agreement)
A re -defined compliance boundary is not needed for this site.
II1. RESTRICTIONS:
Landowner's Certification:
® I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to
make decisions regarding the use of the land application site(s) on behalf of other deeded landowners OR that I
am otherwise authorized, through a power of attorney or other legal delegation. to make decisions regarding the
use of the land application site(s) on behalf of the deeded landowners. I certify that the above -referenced land
application site(s) are not included in any waste disposal contract or agreement with another municipality.
contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement, understand the
stipulations, alternatives for water supply wells insi q the compliance boundary, and restrictions, and do hereby
grant permission to the rmittee to land pply es' als to the land application site(s) as specified herein.
Landowner name:
City: (d // State: Zip: Z- 72,11
Phone:
Sign
Date: �%L / �r-
NORTH GZA OLIVA, bee' -i4P COUNTI'
1, the undersigned Notary Public do hereby certify that r�.� -►
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
day of t c, Y., a^_ 20 \0
Signature and seal: �JAI
My commission expires: a ; - 15 ESTATE
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: -
Lessee/operator address:
City:
Phone:
Signature:
Permittee's Certification:
State: Zip:
Date:
® I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as
specified herein.
Signing official name:—
Signature:Date: 1
ENI) OF FORI\t: LO.. -`
FORM: LOA<, 09040' !,au,-- _, 0:- Anacittnent Order: