WQ0034798_Final Permit_20110218

o
NCDEN
North Carolina Department of EEnvirotlment and Natural Resources
Beverly EEaves Perdue
Governor
John & Shirley Bradsher
991 Old Salem Rd.
Roxboro, NC 27573
Dear John & Shirley Bradsher:
Division of Water Quality
Coleen H. Sullins
Director
February 18, 2011
Subject: Permit No. WQ0034798
Bradsher Single -Fancily
Residence Wastewater
Irrigation System
Person County
Dee Freeman
Secrete.r�
In accordance with your permit application request received May 12, 2010, and subsequent
additional information received July 13, 2010, September 30, 2010, and November 8, 2010, we are
forwarding herewith Permit No. WQ0034798, dated February 18, 2011, to John & Shirley Bradsher, for
the construction and operation of the subject single-family residence wastewater treatment and irrigation
facilities.
This permit shall be effective from the date of issuance until January 31, 2016, and shall be
subject to the conditions and limitations as specified therein. An extension shall be requested at least
six months prior to the expiration of this permit. Upon receipt of the request, the Division will review
the adequacy of the facility described therein and, if warranted, will extend the permit for such period of
time and under such conditions and limitations as it may deem appropriate.
Please pay particular attention to the operation and maintenance requirements listed in Section III.
Failure to establish an adequate system for collecting and maintaining the required operational
information shall result in future compliance problems.
Please note Permit Condition 1.1. which addresses the Setback Waiver:
r Condition I.1. — This condition requires the Permittee to record with the Person County
Register of Deeds, setback waivers within 90 days of permit issuance, for all adjacent
properties that do not meet the required setbacks as noted in the North Carolina
Administrative Code 15A NCAC 02T .0606, and forward copies of the recorded setback
waivers to the Division of Water Quality.
If any parts, requirements or limitations contained in this permit are unacceptable, the Permittee
has the right to request an adjudicatory hearing upon written request within 30 days following receipt of
this permit. 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
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John & Shirley Bradsber WWTS
Page 2of 2
Service Center, Raleigh, NC 27699-6714. Unless such demands are made, this permit shall be final and
binding.
One set of approved plans is being forwarded to you. If you need additional information
concerning this matter, please contact Larry Wade at [phone] or [e-mail].
Sincerely,
C& �, UA
Coleen H. Sullins
cc: Person County Health Department
Raleigh Regional Office, Aquifer Protection Section
Mr. Samuel R. Strickland, PE S and G Engineering Services, Inc.
Ms. Beth Buffington, Technical Assistance and Certification Unit
APS Central Files
LAU Notebook Files

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
John & Shirley Bradsher
Person County
FOR THE
construction and operation of a 360 gallon per day (GPD) single-family residence wastewater treatment
and surface drip irrigation facility consisting of:
Surface drip system with a septic tank, NORWECO Singulair Bio-kenetic treatment system, UV
disinfection, storage and pump tank to serve John & Shirley Bradsher, with no discharge of wastes to
surface waters, pursuant to the application received May 12, 2010, and subsequent additional information
requests received on July 13, 2010, September 30, 2010, and November 8, 2010 by the Division of Water
Quality, and in conformity with the project plans, specifications, and other supporting data subsequently
filed and approved by the Department of Environment and Natural Resources and considered a part of
this permit.
This permit shall be effective from the date of issuance until January 31, 2016, and shall be subject to the
following specified conditions and limitations:
I. SCHEDULES
Within 90 days of permit issuance, the Permittee shall record the Setback Waiver (attached) with the
Person County Register of Deeds, thus allowing irrigation of wastewater effluent generated at the
John & Shirley Bradsher residence within 10 feet of the property boundary, within 22.5 feet of the
identified residence, and construction of treatment units within 12 feet of the property line, of the
residence of the Michael & Jaquelyn Sigmon property, as 'delineated in the Setback Waiver
Agreement. The Permittee shall submit copies of the recorded setback waiver to the Division of
Water Quality, Aquifer Protection Section, 1636 Mail Service Center, Raleigh, NC 27699-1636.
2. Within 90 days of permit issuance, the Permittee shall record the Setback Waiver (attached) with the
Person County Register of Deeds, thus allowing irrigation of wastewater effluent generated at the
John & Shirley Bradsher residence within 10 feet of the property boundary of the residence of the Dr.
James Winslow property, as delineated in the Setback Waiver Agreement. The Permittee shall
submit copies of the recorded setback waiver to the Division of Water Quality, Aquifer Protection
Section, 1636 Mail Service Center, Raleigh, NC 27699-1636.
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3. In accordance with 15A NCAC 02T .0116, upon completion of construction and prior to operation of
this permitted facility, a certification (attached) shall be submitted from a licensed North Carolina
Professional Engineer certifying that the permitted facility has been installed in accordance with this
permit, Division approved plans and specifications, and other supporting documentation, including
the location of all monitoring wells as applicable. If this project is to be completed in phases and
partially certified the Permittee shall retain the responsibility to track further construction approved
under the same ermit and shall provide a final certificate of coin letion once the entire project has
been completed. Mail the Certification to the Division of Water Quality, Aquifer Protection Section,
1636 Mail Service Center, Raleigh, NC 27699-1636.
4. The Raleigh Regional Office, telephone number [phone], shall be notified at least 48 hours in
advance (excluding weekends and holidays) of operation of the installed facilities such that an in -
place inspection can be made. Notification to the Aquifer Protection Section's regional supervisor
shall -be made from .8:00 a.m. until 5:00 p.m. on Monday through Friday, excluding State Holidays.
5. No later than six months prior to the expiration of this permit, the Permittee shall request renewal of
this permit on official Division forms. Upon receipt of the request, the Division will review the
adequacy of the facilities described therein., and if warranted, will renew the permit for such period of
time and under such conditions and limitations as it may deem appropriate. Please note Rule 15A
NCAC 02T .0105(d) requires an updated site map to be submitted with the permit renewal
application.
6. In accordance with 15A NCAC 02T .0607, if a public or community sewage system is or becomes
available, the subject single-family residence wastewater treatment and irrigation facilities shall be
closed and all wastewater shall be discharged into the public or community sewage system within 180
days of its availability. Prior to the initiation of these connection activities, appropriate Division
approval shall be received,
II. PERFORMANCE STANDARDS
The subject non -discharge facilities shall be effectively maintained and operated at all times so tkere
is no discharge to surface waters, nor any contravention of groundwater or surface water standards.
In the event the facilities fail to perform satisfactorily, including the creation of nuisance conditions
due to improper operation and maintenance, or failure of the irrigation areas to adequately assimilate
the effluent, the Permittee shall take immediate corrective actions including Division required actions,
such as the construction of additional or replacement wastewater treatment or disposal facilities.
2. This permit shall not relieve the Permittee of their responsibility for damages to groundwater or
surface water resulting from the operation of this facility.
Application rates, whether hydraulic, nutrient or other pollutant, shall not exceed those specified in
the following table:
TABLE I —APPLICATION LIMITATIONS
Field
Parameter
Hourly Rate
Yearly Max
Units
1
Design Load Rating
0.010
16.73
inches
4. The subject facility has been approved to land apply wastewater effluent on the following fields:
TABLE 2 — IRRIGATION AREA INFORMATION
Field
Owner
County
Latitude
Longitude
Net
Acreage
Dominant
Soil Series
1
John & Shirley Bradsher
Person
36.4416
79.1011
0.347
Enon
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5. The Operation and Maintenance Agreement (attached) between the Permittee and the Division of
Water Quality is incorporated herein by reference and shall be a condition of this permit.
Noncompliance with the terms of the Operation and Maintenance Agreement shall subject the
Permittee to all sanctions provided by North Carolina General Statutes § 143-215.6A to § 143-215.6C
for violation of or failure to act in accordance with the terms and conditions of this permit.
6. The irrigation system shall be connected to a rain or moisture sensor, which shall indicate when
effluent application is not appropriate in accordance with Conditions III.4. and III.5. of this permit.
7. In accordance with 15A NCAC 02L .0107(i), the compliance boundary is established at the property
boundary. Any exceedance of standards at the compliance boundary shall require action in
accordance with 15A NCAC 02L .0106.
8. In accordance with 15A NCAC 02L .0108, the review boundary is established midway between the
compliance boundary and the effluent disposal area. Any exceedance of groundwater standards at the
review boundary shall require action in accordance with 15A NCAC 02L .0106.
9. The Permittee shall apply for a permit modification to establish a new compliance boundary prior to
any sale or transfer of property affecting a compliance boundary.
10. Setback waiver forms have been submitted for allowing a variance in the setback requirements for the
adjacent properties owned by Dr. James Winslow, and Michael & Jaquelyn Sigmon, to allow a
decrease in the setbacks noted below and are attached to and made part of this permit. Other than the
aforesaid setback waivers, the facilities permitted herein shall be constructed according to the
following setbacks:
a. The setbacks for irrigation sites permitted shall be as follows (all distances in feet):
i. Any habitable residence or place of public assembly under separate ownership:
100
ii. Any habitable residence or place of public assembly owned by the Permittee:
15
iii. Any private or public water supply source:
100
iv. Surface waters:
100
v. Groundwater lowering ditches:
100
vi, Surface water diversions:
25
vii. Any well with exception of monitoring wells:
100
viii. Any property line:
50
ix. Top of slope of embankments or cuts of two feet or more in vertical height:
15
x. Any water line from a disposal system:
10
xi. Subsurface groundwater lowering drainage systems:
100
xii. Any swimming pool:
100
xiii. Public right of way:
50
xiv. Nitrification field:
20
xv. Any building foundation or basement:
15
b. The setbacks for storage and treatment units permitted shall be as follows (all distances in feet):
L Any habitable residence or place of public assembly under separate ownership
ii. Any private or public water supply source:
iii. Surface waters:
iv. Any well with exception of monitoring wells:
v. Any property line:
100
100
50
100
50
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IV.
OPERATION AND MAINTENANCE REQUIREMENTS
1. The facilities shall be properly maintained and operated at all times, The facilities shall be effectively
maintained and operated as a non -discharge system to prevent the discharge of any wastewater
resulting from the operation of this facility, The Permittee shall maintain an Operation and
Maintenance Plan pursuant to 15A NCAC 02T .0604(1).
2. Upon the Water Pollution Control System Operators Certification Commission's (WPCSOCC)
classification of the subject non -discharge facilities, in accordance with 15A NCAC 08G .0200 the
Permittee shall designate and employ a certified operator in responsible charge (ORC) and one or
more certified operator(s) as back-up ORC(s). The ORC or their back-up shall visit the facilities in
accordance with 15A NCAC 08G .0200, and shall comply with all other conditions specified in the
previously cited rules,
3. A suitable year round vegetative cover shall be maintained at all times, such that crop health is
optimized, allows for even distribution of effluent and allows inspection of the irrigation system.
4. Adequate measures shall be taken to prevent effluent ponding in or runoff from the irrigation sites
listed in Table 2 of Condition 11.4.
5. Irrigation shall not be performed during inclement weather or when the ground is in a condition that
will cause ponding or runoff.
6. Only effluent from the Bradsher Single Family Residence Wastewater Irrigation System shall be
irrigated on the sites listed in Table 2 of Condition 11.4.
7. No automobiles or machinery shall be allowed on the irrigation sites except during equipment
installation or while maintenance is being performed.
8. Public access to the irrigation sites and wastewater treatment facilities shall be prohibited. Fencing
shall be provided to prevent access to the irrigation site (minimum 2-strand wire) and treatment units
shall be secured with locks on all tank accesses and control panels.
9. The residuals generated from the wastewater treatment facilities shall be disposed or utilized in
accordance with 15A NCAC 02T .1100.
10. Diversion or bypassing of untreated or partially treated wastewater from the treatment facilities is
prohibited.
11, Pump/dosing tanks shall have audible and visual alarms external to any structure.
12. Any excavation into bedrock shall be lined with a 10 millimeter (mm) synthetic liner.
13. A water -tight seal on all treatment/storage units or minimum of two feet protection from the 100-year
flood plain elevation shall be provided.
MONITORING AND REPORTING REQUIREMENTS
1, Any Division required monitoring (including groundwater, plant tissue, soil and surface water
analyses) necessary to ensure groundwater and surface water protection shall be established. and an
acceptable sampling reporting schedule shall be followed.
2. Noncompliance Notification:
The Pernaittee shall report by telephone to the Raleigh Regional Office, telephone number (919) 791-
4200, as soon as possible, but ,in no case more than 24 hours, or on the next working day following
the occurrence or first knowledge of the occurrence of any of the following:
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a. Any process unit failure (e.g., mechanical, electrical, etc.), due to known or unknown reasons,
rendering the facility incapable of adequate wastewater treatment.
b. Any facility failure resulting in a by-pass directly to receiving surface waters.
c. Any time self -monitoring indicates the facility has gone out of compliance with its permit
limitations.
d. Ponding in or runoff from the irrigation sites.
Any emergency requiring immediate reporting (e.g., discharges to surface waters, imminent failure of
a storage structure, etc.) outside normal business hours shall be reported to the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone].
Persons reporting such occurrences by telephone shall also file a written report in letter form within
five days following first knowledge of the occurrence. This report shall outline the actions taken or
proposed to be taken to ensure the problem does not recur.
V. INSPECTIONS
1. The Permittee shall provide adequate inspection and maintenance to ensure proper operation of the
wastewater treatment and irrigation facilities.
2. The Permittee or their designee shall inspect the wastewater treatment and irrigation facilities to
prevent malfunctions, facility deterioration and operator errors resulting in discharges, which may
cause the release of wastes to the environment, a threat to human health or a public nuisance. The
Permittee shall maintain an inspection log that includes, at a minimum, the date and time of
inspection., observations made, and any maintenance, repairs, or corrective actions taken. The
Permittee shall maintain this inspection log for a period of five years from the date of the inspection,
and this log shall be made available to the Division upon request.
3. Any duly authorized Division representative may, upon presentation of credentials, enter and inspect
any property, premises or place on or related to the wastewater treatment and irrigation facilities
permitted herein at any reasonable time for the purpose of determining compliance with this permit;
may inspect or copy any records required to be maintained under the terms and conditions of this
permit, and may collect groundwater, surface water or leachate samples.
VI. GENERAL CONDITIONS
1. Failure to comply with the conditions and limitations contained herein may subject the Permittee to
an enforcement action by the Division in accordance with North Carolina General Statutes 143-
215.6A to 143-215.6C.
2. This permit shall become voidable if the permitted facilities are not constructed in accordance with
the conditions of this permit, the Division approved plans and specifications, and other supporting
documentation.
3. This permit is effective only with respect to the nature and volume of wastes described in the permit
application, Division approved plans and specifications, and other supporting documentation. No
variances to applicable rules governing the construction or operation of the permitted facilities are
granted, unless specifically requested and approved in this permit pursuant to 15A NCAC 02T
.0105(n).
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4. The issuance of this permit does not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances, which may be imposed by other jurisdictional government agencies
(e.g., local, state, and federal). Of particular concern to the Division are applicable river buffer rules
in 15A NCAC 02B .0200; erosion and sedimentation control requirements in 15A NCAC Chapter 4
and under the Division's General Permit NCG010000; any requirements pertaining to wetlands under
15A NCAC 02B .0200 and 02H .0500; and documentation of compliance with Article 21 Part 6 of
Chapter 143 of the General Statutes.
5. In the event the permitted facilities change ownership or the Permittee changes their name, a formal
permit modification request shall be submitted to the Division. This request shall be made on official
Division forms, and shall include appropriate property ownership documentation and other supporting
documentation as necessary. The Permittee of record shall remain fully responsible for maintaining
and operating the facilities permitted herein until a permit is issued to the new owner.
6. The Permittee shall retain a set of Division approved plans and specifications for the life of the
facilities permitted herein.
7. The Permittee shall maintain this permit until all permitted facilities herein are properly closed or
permitted under another permit issued by the appropriate permitting authority pursuant to 15A NCAC
02T .01050).
8. This permit is subject to revocation or unilateral modification upon 60 days notice from the Division
Director, in whole or part for the requirements listed in 15A NCAC 02T .0110.
9. Unless the Division Director grants a variance, expansion of the permitted facilities contained herein
shall not be granted if the Permittee exemplifies any of the criteria in 15A NCAC 02T .0120(b).
10. The Permittee shall pay the annual fee within 30 days after being billed by the Division. Failure to
pay the annual fee accordingly shall be cause for the Division to revoke this permit pursuant to 15A
NCAC 02T .0105(e)(3).
Permit issued this the 18th day of February, 2011,
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
oleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number WQ0034798
WQ0034798 Version 1-0 Shell Version 091027 Page 6 of 8

Permit No. WQ0034798
John & Shirley Bradsher
B radsher W WT S
ENGINEERING CERTIFICATION
❑ Partial ❑ Final
Single Family Residence
February 18. 2011
Person County
In accordance with 15A NCAC 02T .0116, I,_ ,
as a duly registered Professional Engineer in the State of North Carolina, having the Permittee's
authorization to ❑ periodically ❑ weekly ❑ fully observe the construction of the permitted facility,
hereby state to the best of my abilities that due care and diligence was used in the observation of the
construction, such that the facility was built within substantial compliance and intent of this permit, the
Division approved plans and specifications, and other supporting documentation.
❑ Any variation to this permit, the Division approved plans and specifications, and other supporting
documentation has been documented in the attached as -built drawings, and shall serve as the
Pennittee's minor modification request to amend the permit accordingly.
Provide a brief narrative description of any variations:
Professional Engineer's Name
Engineering Firm
Mailing Address
City
State Zip
Telephone E-mail NC PE Seal, Signature &, Date
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
LAND APPLICATION UNIT
By U.S. Postal Service: By Courier/Special Delivery:
1636 MAIL SERVICE CENTER 2728 CAPITAL BOULEVARD
RALEIGH, NORTH CAROLINA 27699-1636 RALEIGH, NORTH CAROLINA 27604
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State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEMS
OPERATION AND MAINTENANCE AGREEMENT
FORM: SFRWWIS O&M 03-10
Permit No. S PF-ST A Cyr-o �
County: oc41< c, n
Property owner(s) as appearing on the recorded deed: +�_ g r — CA S lk
Mailing address: Sc,(," 1p=�)
Facility address: C A- -5 4,� L C_ f<sc.,, ..r- v,
Irrigation Method: ❑ SPRAY [" DRIP
I 1 We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as follows:
1. The Permittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed.
b. The septic tank effluent filter shall be checked and cleaned annually.
c. Accessible sand filter surfaces shall be raked and leveled every six months and any vegetative growth shall be
removed manually.
d. ❑ The tablet chlorinator shall be checked weekly and tablets shall be added as needed to provide proper
chlorination, OR
["The ultraviolet disinfection unit shall be checked weekly and the lamp(s) shall be cleaned or replaced to
ensure proper disinfection.
e. All pump and alarm systems shall be inspected monthly.
f. The irrigation system shall be inspected monthly to ensure that vegetative growth does not interfere with the
system inspection or operation, that the soil is assimilating the disposed treated wastewater with no visible
runoff or panding, and that no objectionable odors are being generated.
2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T
.0105(c)(3).
3. The Permittee's failure to properly operate this system is subject to a penalty up to $25,000 per day.
4. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void
the permit.
All owners appearing on the legally recorded property deed shall si n this Operation & Maintenance Agreement
I / We understand the above requirements and agree to these terms as part of the issued permit.
Owner Signature: �" /f - "' �" 4� Dater—e6
Owner Signature:
i
imq, � 2 01[1
FORM: SFRWWIS O&M 03-10 Page 1 of 1

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
NON-DISCHAR--GE WASTEWATER SYSTEM WAIVER
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGLNAL)
The Division of Water Quality will not consider this form complete unless all instructions are followed. Failure to
Mow instructions or to submit all required items wadi lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
hrr :! ortal,ncderrr.ur ;'web,%w is s/lazL ypplicaLons.
rNSTRUMONS TO THE APPLICANT: ,
Do not submit this form for review without a corresponding Land Application Unit application form.
✓ Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by 15A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WANE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) and .1006(a)
The undersigned property owner(s) hereby permits:
Applicant's name: John R. Bradsher
Complete mailing address of applicant: 991 Old. Salem Rd.
City: Roxboro State: NC Zip: 27573
Telephone number: (_336_) 599-7413
Facsimile number: L�
Hereinafter referred to as the Permittee, to (check all that apply):
❑ Non -Discharge disposal of wastewater effluent within 10 feet of the property line,
❑ Non -Discharge disposal of wastewater effluent within 22.5 feet of the identified residence,
❑ Construct treatment and storage units within 12 feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM: NDWWSSW 11-09

The w*ed setbacks apply as shown on the attached map and located at the following:
Location address of property:
is Person Co State: NC Zip: 27573
gI certify that I am a deeded properly 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 dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further Wee that upon the Division of Water Quality's
issuance of a permit for the subiect non-diseharee system. I will record this waiver form with the awronriate Register
of Deeds and orovide the Permittee and Division of Water OualitV with documentation of such.
Property o s)- -4 --Ta.c. , s �� m and
Signature:Date:
r�Signature:
Date: 3- t - 2,- 10
NORTH CAROLINA, fiepb on% Co �/�✓� COUNTY
Iti 40 A , a Notary Public for FeI S p A) County, North Carolina,
do hereby certify that 1 C 6e 1 5 ; n/ - ry C N �jo personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Fitness my hand and official seal this the day of
SEAL
Signature of Notary Pub
My commission expires
FORM: NDWWSSW 11-09

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
NON -DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM MA Y BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Quality will not consider this form complete unless all instructions are followed. Failure to
follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
httn: mortal. ncdenr. or,��w�h- tis�q��,silauiannlications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Land Application Unit application form.
Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by 15A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(h), .0606(a), .0706(a) and .1006(a)
The undersigned property owner(s) hereby permits:
Applicant's name: Join R. Bradsher
Complete mailing address of applicant: 991 Old Salem Rd.
City: Roxboro State: NC Zip: 27573
Telephone number: L336_) 599-7413 Facsimile number: (�
Hereinafter referred to as the Permittee, to (check all that apply):
❑ Non -Discharge disposal of wastewater effluent within 10 feet of the property line,
❑ Non -Discharge disposal of wastewater effluent within feet of the identified residence,
Construct treatment and storage units within feet of the property line,
[� Construct treatment and storage units within feet of the identified residence.
FORM: NDWWSSW 11-09

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: Lot 15 Stonegate Dr
r''*y: Person Co State: NC Zip: 27573
[� 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 dispose of wastewater effluent or
construct wastewater treatment units as specified herein. I further agree that upon the Division of Water Quality's
issuance of a permit for the subject non -discharge system, I will record this waiver form with the appropriate Register
of Deeds and provide the Permittee and Division of Water Quality with documentation of such.
Property o
Signature:
Signature:
NORTH CAROLINA,
do hereby certify that
M
PC '5'0 `) COUNTY
a Notary Public for
acknowledged the due execution of the foregoing instrument.
Witness my hand and,ofFicial seal this the I i day of
SEAL
RECEIVED 1 DENR 1 DWQ
Aquifer Protection Section
APR 20 2010
FORM: NDWWSSW 11-09
Date:
c2r d
Date:
A/S 0 r�J County, North Carolirti
personally appeared befm)ee me this day and
�e� doll)
, GCS j�- . � 4Z
Signature of Notary Public
My commission expires 9 �'