WQ0007349_Renewal Application_20190319

INITIAL REVIEW
Reviewer Thornburg, Nathaniel
Project Number* WQ0007349
SUBMITTAL DATED: 3/4/2019
Project Contact Information
Rease provide inforrration on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other issues.
......................................................................................................................................................................................................................................................................................................................................................................................................
Name * Zach Key
Email Address*
[e-mail]
Project Information
.... .............................. ...................
Application Type* r
New
r
Renewal
r
Annual Report
Permit Type * r
Wastewater Irrigation
r
Other Wastewater
r
Closed -Loop Recycle
r
Single -Family Residence
Wastewater Irrigation
Is a paper copy of the application being submitted?*
r Yes r Nor N/A
Permit Number WQ0007349
currently has project
Permittee * Yadkin Valley Sewer Authority
Facility Name * Yadkin Valley Sewer Authority
Phone Number*
3369577871
r Modification (Major or Minor)
r Additional Information
r Other
r High -Rate Infiltration
r Reclaimed Water
r Residuals
r Other
Please provide comments/notes on your current submittal below.
Please attach all information required or requested for this submittal to be review here.
Application Form Engineering Rans, Specifications, Calculations, @c.)
YVSA WQ0007349 2019 Renewal.pdf 5.09MB
Wload only 1 RDF document. NUltiple documents rust be contained into one RDF file.

For nein and modif cation permit applications, the paper copy is required to be submitted to the
Di, risiom Be advised, applications will not be considered complete until both the paper and electronic
applications. have been received_ The paper copy shall include the follm ging:
• Application Farm
• All relevant attachments (talcs, soils report, specs, etc_)
• 1 full-size engineering plan set
• 2 11-17" engineering plan sets
• 1 extras set of specifications (in addition to the set of specifications Provided in the
attachments)
• Fee (if required)
This shall be mailed to the following address:
By US_ Postal Service-
Di,vision of Water Resources- Non -Discharge Branch
1617 Mail Service Center Raleigh NC 27699-1617
By Courier, -Special Delivery:
Division of Water Resources- Non -Discharge Branch
Nathaniel Thornburg- 9th Floor, Office #942M
512 N_ Salisbury St_ Raleigh, NC 27644
For questions or problems contact Tessa Monday at 919.7073660 or Tessa_X%nday(dncdem_gov or
Sonia Graves at 919.707.3657 or Sonia Graves(dpcdenr.gov.
*140 By checking this box I am acknowledging that I have read the above statement and agree
to send these documents as required to one of the address given above.
Signature
Submission Date 3/4/2019

S IlSouthern 958 Hoots Road Roaring River, NC 28669
S SOI( Zach Key 336-957-7871 • Fax [phone]
Email: [e-mail]
B Builders, Inc.
Monday, March 4, 2019
North Carolina Department of Environmental Quality
Division of Water Resources
Water Quality Permitting Section
Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, INC 27699-1617
Reference: Permit Renewal for the Yadkin Valley Sewer Authority
Land Application Permit No. WQ0007349
The Yadkin Valley Sewer Authority is applying for a renewal to its current land application permit
WQ007349.
There are no modification to this renewal with the exception of:
1. Fields PPI, PP2, PP2A, PP3, PP4, TC6 are not being renewed at this time due to internal
landowner disagreements with the trust. If this issue gets resolved, we may add these fields back in the
future.
Your attention to this permit application package is greatly appreciated. If you have any questions or
concerns, please feel free to contact me at 336-957-7871 or at [e-mail]
Sincerely,
;Z�
ach Key
Southern Soil Builders, Inc.

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T.1100 — RESIDUALS LAND APPLICATION PROGRAM
INSTRUCTIONS FOR FORM: RLAP 06-16 & SUPPORTING DOCUMENTATION
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted. the Applicant shall submit one orieinal and two conies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General — This application is for treatment, storage, transport, and/or land application of Class B residuals (may include residuals that
are generated from a water treatment plant or other type facilities) on the proposed or currently approved land application site(s) under
15A NCAC 02T.1 100.
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Land Application Program (FORM: RLAP 06-16) Application: (All Application Packages):
❑ Submit the completed and appropriately executed Residuals Land Application Program (FORM: RLAP 06-I6) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
EJ The Applicant's Certification on Page 5 of this form shall be signed in accordance with 15A NCAC 02T 0106(b). An alternate
person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 15A
NCAC 02T.0 106(b).
❑ If this project is for a modification of an existing permit, submit one copy of the existing permit.
❑ Please submit this application form at least 180 days prior to the expiration date on the existing permit, or 90 days prior to
operation of proposed facility(ies) for application packages involving new or changes to treatment and storage units.
B. Application Fee (New and Major Modification Application Packages)
❑ Submit a check, money order or electronic funds transfer made payable to: North Carolina Department of Environmental
Quality (NCDEQ).
Facility Classification ! New Permit
i
Major (land are permitted for > 300 acres) $1,310
Minor (land are permitted for < 300 acres) $810
Major Modification
$395
$245
- A major modification shall be defined as any permit modification that: increases the generating facility's residuals dry tonnage;
adds additional land application areas not previously approved for that particular program [including transferring of field(s) from
one program to another]; adds additional residuals sources; or includes the addition of new treatment or storage units/processes not
previously permitted. There is no fee for minor modifications to a permit.
C. Cover Letter (All Application Packages)
❑ List all items included in the application package, as well as a brief description of the requested permitting action.
D. Environmental Assessments (May be Required — See 15A NCAC IC .0300)
❑ Submit a copy of the Findings of No Significant Impact (FONSI) or Environmental Impact Statement (EIS). Also, include
information on any mitigating factor(s) from the Environmental Assessment (EA) that impact the construction of the residuals
treatment and storage facilities. An EA may also be required for private systems if any public funds and/or lands are used for
the construction of the subject facilities.
INSTRUCTIONS FOR FORM: RLAP 06-16 Page I of 3

E. Operation and Maintenance Plan (New and Renewal Application Packages)
For Modification Application, if there are any changes to the existing plan, submit an updated O&M plan.
❑ Submit the O&M Plan in accordance with 15A NCAC 02T. I I 10 and include at a minimum:
❑ Operational functions; describe the operation of the program to show what operations are necessary for the program to
function and by whom the functions are to be conducted.
❑ Maintenance schedules; may include equipment calibration, maintenance of signs, etc.
Safety measures; may include safety training program, manuals, signs, etc.
❑ Spill response plan; including control, containment, remediation, emergency contact information, etc.
❑ Inspection plan including the following information;
❑ Names and titles of personnel responsible for conducting the inspections.
❑ Frequency and location of inspections, including those to be conducted by the ORC, and procedures to assure that the
selected location(s) and inspection frequency are representative of the residuals management program.
❑ Detailed description of inspection procedures including record keeping and actions to be taken by the inspector in the event
that noncompliance is observed.
❑ Sampling and monitoring plan including the following information;
❑ Names and titles of personnel responsible for conducting the sampling and monitoring.
❑ Detailed description of monitoring procedures including parameters to be monitored.
❑ Sampling frequency and procedures to assure that representative samples are being collected. Fluctuation in temperature,
flow, and other operating conditions can affect the quality of the residuals gathered during a particular sampling event. The
sampling plan shall account for any foreseen fluctuations in residuals quality and indicate the most limiting times for
residuals to meet pathogen and vector attraction reduction requirements (e.g. facilities that land apply multiple times per
year but have an annual sampling frequency, may need to sample during winter months when pathogen reduction is most
likely to be negatively affected by cold temperatures.
THE FOLLOWING ADDITIONAL ITEMS (G to M) ARE REQUIRED FOR DEDICATED PROGRAM ONLY,
F. Program Determination
❑ Dedicated residuals land application programs are ones in which land application sites meet the criteria in 15A NCAC 02T
.1102(12 . Specifically, a residuals land application program is designated as dedicated if any of the following are applicable:
❑ Any land application site certified for the residuals land application program that receives residuals at rates or frequencies
greater than agronomic rates.
❑ Any land application site certified for the residuals land application program that is used primarily for residuals disposal,
and agricultural crop production is of secondary importance.
❑ Any land application site certified for the residuals land application program that receives residuals through fixed irrigation
facilities or irrigation facilities fed through a fixed supply system.
❑ Please contact the Non -Discharge Permitting Unit if you need any assistance in determining whether your residuals program
falls under the dedicated program definitions.
G. Program Information
❑ Provide an explanation of why a dedicated system is required instead of a conventional non -dedicated system,
❑ Provide an explanation of the dedicated system and its operation.
H. Detailed Site Maps (All New or Modification Application Packages)
❑ Submit three (3) sets of standard size plans and two (2) sets of I P by 17" plans (electronic format is acceptable - Adobe PDF
only). For Modifications, submit plans specific to the modification(s) only.
❑ Plans must include the following minimum items:
❑ A general location map, a vicinity map and a topographic map with contours not exceeding 10 feet or 25% of the total site
relief and showing all facility related structures and fences within the land application area.
❑ The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of the land application site(s).
❑ Delineation of the review and compliance boundaries
❑ Setbacks as required by 15A NCAC 02T .1108
❑ Site property boundaries within 500 feet of all waste treatment, storage, and disposal site(s).
A map showing the entire irrigation area with an overlay of the suitable irrigation area depicted by the soil scientist's
evaluation. The irrigation plans shall show each nozzle/emitter and wetted area (when applicable). Clearly label spray
irrigation zones as they will be operated.
❑ Plans must depict a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY, NOT FOR
CONSTRUCTION, etc.) that indicate that they are anything other than final plans. However, the plans may be labeled with
the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION
INSTRUCTIONS FOR FORM: RLAP 06-16
Page 2 of 3

1. Project Evaluation and Receiver Site Management Plan (All New Application Packages or Modifications that include new sites)
❑ Submit a project evaluation and a receiver site management plan (if applicable) with recommendations concerning cover crops
and their ability to accept the proposed application rates.
J. Hydrogeologic Report (All New Application Packages or Modifications involving increasing the total design capacity)
❑ Submit a detailed hydrogeologic evaluation in. accordance with I5A NCAC 02T 1104(d)(4) and current Division Policy
available at: essio htt]D://www.ncwa or /Rule Policies and Reeulauons/. The document shall be signed, sealed and dated by a
qualified professional.
K. Engineering Design Documents (All New or Modification Application Packages with fixed irrigation facilities or irrigation
facilities fed through fixed supply system)
L.
M.
❑ Submit engineering design documents that have been signed, sealed, and dated by a NC licensed Professional Engineer and/or
Professional Land Surveyor in accordance with 15A NCAC 02T 1104(d)(2). For Modifications, submit an updated site map
specific to the modification(s) only.
❑ The design documents must include the following minimum items:
Engineering plans for the facility and equipment except those previously permitted unless they are directly tied into the new
units or are critical to the understanding of the complete process;
❑ Specifications describing materials to be used, method of construction, and means for ensuring quality and integrity of the
finished product including leaking testing; and
❑ Engineering calculations including hydraulic and pollutant loading, sizing criteria, hydraulic profile, total dynamic head
curve analysis for each pump, and irrigation design.
❑ Soil mapping units shown on all disposal sites.
Water Balance (All New Application Packages or Modifications that include new sites utilizing fixed irrigation facilities or
irrigation facilities fed through fixed supply systems)
❑ Submit a completed and accurate water balance in accordance with 15A NCAC 02T 1104(d)(5) and current Division Policy
available at: http://www.ncwater.or/Rules Policies and Regulations/.
Property Ownership Documentation (All New or Modification Application Packages involving new and/or relocated treatment
or irrigation components)
❑ Property ownership documentation shall consist of one of the following:
❑ Legal documentation of ownership (i. e., GIS, deed or article of incorporation), or
Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
An easement running with the land specifically indicating the intended use of the property and meeting the requirements of
15A NCAC 02L 0107(f), or
❑ A written notarized lease agreement signed by both parties, indicating the intended use of the property, as well as a plat or
survey map.
ONE ORIGINAL AND TWO COPIES OF THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL
SUPPORTING INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service: By Courier/Special Delivery:
1617 MAIL SERVICE CENTER 512 N. SALISBURY STREET
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone] FAX NUMBER: [phone]
INSTRUCTIONS FOR FORM: RLAP 06-16 Page 3 of 3

DWR State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T .1100 — RESIDUALS LAND APPLICATION PROGRAM
FORM: RLAP 06-16
1. APPLICANT INFORMATION:
Applicant's name: Yadkin Valley Sewer Authority
Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑Privately -Owned Public Utility
Federal ❑ State Municipal ❑ County
Signature authority's name per 15A NCAC 02T 0106: Nicole Johnston Title: Executive Director
Applicant's mailing address: PO Box 828
City: Elkin State: NC Zip: 28621
Telephone.number: [phone] Email Address: [e-mail]
2. Consultant's name: Zach Key License Number (for P.E.):
Affiliation: ❑ On Staff 0 Retained (Firm: Southern Soil Builders Inc.)
Consultant's mailing address: 1151 Wagon Ride Road
City: Roaring River State: NC Zip: 28669
Telephone number: [phone]
3. Agronomist's name: _
Affiliation: ❑ N/A ❑ On Staff
Agronomist's mailing address: _
City: — State: _
Email Address: zachkev@gouthernsoilbuilders corn
License Number: _
❑ Retained (Firm: _)
Zip: _-
Telephone
Telephone number: (_) — _ Email Address: _
4. Soil Scientist's name: License Number:
Affiliation: ❑ N/A ❑ On Staff ❑ Retained (Firm: _)
Soil Scientist's mailing address: _
City: — State: _ Zip:
Telephone number: (_) _ _ Email Address: _
5. Fee submitted: $0.00 (See Instruction B)
H. PERMIT INFORMATION:
1. Application is for (check all that apply): ❑ new, ❑ modified,
® renewed permit
2. If this application is being submitted to renew or modify an existing permit, provide the following:
Permit number: WO0007349
Date of most -recently issued permit: 07-10-2014
Date of most -recently certified Attachment A (if different than the permit): 12-19-2016
Date of most -recently certified Attachment B (if different than the permit): 12-19-2016
FORM: RLAP 06-16
Page 1 of 5

111. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
1. Residuals Processing Facility's physical address: 200 Marion Street
City: Elkin State: NC
Zip: 28621
Coordinates: Latitude: 36° 49'24.58"
Longitude: -80° 49'57_66"
Datum: NAD83
Level of accuracy: .01
Method of measurement: MAP
2. County where residuals land application program is headquartered: Surry
3. List the Operator In Responsible Charge (ORC) and all Back -Up ORCs for the residuals land application program, their
certification numbers, and their affiliations in the following table:
Designation Name
ORC Dennis Key
Back -Up ORC Zach Key
ditional Back -Up
ORCs
Affiliation
Southern Soil Builders, Inc.
Southern Soil Builders, Inc.
Certification Number
13532
27660
If an ORC and at least one Back -Up ORC are not currently designated for this residuals land application program, provide the
candidates' names, affiliations, and an estimated time schedule for each candidate's completion of the required training school
and certification test:
4. Complete the following tables regarding management of the residuals land application program:
a. PiantAvaiiabie Nitronen Summary. Determine the maximum plant available nitrogen (PAN) generated by all residuals
source -generating facilities as currently certified and proposed for certification with this application and list the results in the
following table:
Maximum amount of residuals to be certified: 250 dry tons per year.
PAN
Pounds of PAN per Dry Ton
(Weighted Average)
Pounds of PAN per Year
Surface
Incorporation
or Injection
Surface
Incorporation
or Injection
First -Year
29.882
37.972
7470.5
9493
Five -Year Maximum Adjusted
31.9
40.6
7975
10115
b. Landjpg ication Site Use Summary: Summarize information regarding the land application sites as currently certified and
proposed for certification with this application:
Category
Use
Acres
Comments
Crops
Forest or Plantation
0
Row Crops
36.82
Hay
80.52
Pasture
33
149.4
Total:
150.34
Methods
Surface
113.52
Incorporation or Injection
36.82
Total:
150.34
FORM: RLAP 06.16
Page 2 of 5

c. Residuals Laad AOp([CarlaIt Summary: Determine the minimum acreage required to land apply the residuals as currently
certified and proposed for certification assuming the scenarios listed in the following table:
Assumed
Application Rate
Acres Required Using
First -Year PAN Concentrations
Acres Required Using
Five -Year Maximum Adjusted PAN
(lbs PAN/ac-yr)
Concentrations
Surface Incorporation or
Surface Incorporation or
Injection
Injection
50
149.4 189.86
159.5 202.3
100
74.7 94.9
79.5 101.1
150
49.8 63.3
53.1 67.4
200
37.3 47.5
39.8 50.5
6. If applicable, provide a plan and a schedule to resolve any known issues that would prevent land application of the proposed
residuals due to the violation of North Carolina Administrative Code (e.g. not enough storage, not enough land, vector reduction
practices not in place, etc.):
7. Specify type of residuals program (See Instruction F): Z Non -dedicated ❑ Dedicated
If Dedicated, specify the following (check all that apply):
❑ Residuals program contains any land application site(s) that receives residuals at rates or frequencies greater than agronomic
rates, explain; _
❑ Residuals program contains any land application site(s) that is used primarily for residuals disposal, and agricultural crop
production is of secondary importance, explain; _
❑ Residuals program contains any land application site(s) that receives residuals through fixed irrigation facilities or irrigation
facilities fed through a fixed supply system, explain; _
IV. RESIDUALS SOURCE INFORMATION: (Required for all new, renewed, or modified residuals source)
Complete and submit the following Residuals Source Certification and all associated documentation.
Residuals Source
Certification
V. LAND APPLICATION SITE INFORMATION: (Required for all new, renewed, or modified land application site)
Complete and submit the following Land Applications Site Certification and all associated documentation.
Land Application Siite
Certification. doc
FORM: RLAP 06.16
Page 3 of 5

Note: Item VI. Applicable to Dedicated Program with fixed irrigation system only.
VI. DESIGN INFORMATION FOR FIXED IRRIGATION SYSTEM
I. The irrigation system is: ❑ Spray ❑ Drip
2. Disposal system is: ❑ existing ❑ proposed.
3. Minimum depth to mean seasonal high water table (SH WT) within irrigation sites(s) per Soil Scientist's Evaluation: _ feet
below ground surface. Rules 15A NCAC 02T 0505(0) requires at least one -foot vertical separation between SHWT and ground
surface.
4. Are there any artificial drainage or water movement structures within 200 feet of any irrigation area?
C Yes or ❑ No If Yes, please explain if the soil scientist report addresses artificial structures and please indicate if
structures are to be maintained or modified:
5. Loading rates recommended by the Soil Scientist Evaluation:
Soil Series
Recommended
Fields within Soil Area Loading Rate
in/hr
Recommended
Loading Rate
in/ r
It
Nozzle capacity
gpm
Nozzle manufacturer / model
Elevation of highest nozzle
ft
6. Design loading rates are equal or less than the loading rates recommended by Soil Scientist?
❑ Yes or ❑ No If No, explain why 15A NCAC 02T 0505(n) is not met:
7. Non -dedicated System Design (fill in the appropriate information for either a spray or drip irrigation system):
Field / Zone Design Area
ftz
Number of Maximum Application
Nozzles Rate allons/hr
Design Annual Loading
Rate allons/ r
It
Nozzle capacity
gpm
Nozzle manufacturer / model
Elevation of highest nozzle
ft
Total
Spray Irrigation Design Element
Wetted diameter of nozzles
Plan Sheet Specification
Number —Page Number
ft
Wetted area of nozzles
It
Nozzle capacity
gpm
Nozzle manufacturer / model
Elevation of highest nozzle
ft
FORM: RLAP 06-16 Page 4 of 5

Applicant's Certification (signing authority must be in compliance with 15A NCAC 02T.0106):
The applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without proper
closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are compliant with any active
compliance schedule, and do not have any overdue annual fees under Rule 15A NCAC 02T .0105.
0 Yes ❑ No, Explain;
I, Nicole Johnston
(Signature Authority's Name — PLEASE PRINT) Executive Director
(Title)
attest that this application for _ Yadkin Valley Sewer Authoritv
(Facility Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that the Division of Water Resources
may not conduct a technical review of this program and approval does not constitute a variance to any rules or statutes unless specifically
granted in the permit. Further, any discharge of residuals to surface waters or the land will result in an immediate enforcement action,
which may include civil penalties, injunctive relief, and/or criminal prosecution. 1 will make no claim against the Division of Water
Resources should a condition of this permit be violated. I also understand that if all required parts of this application are not completed
and that if all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
Note: In accordance with North Carolina General Statutes § 143-215.6A and § 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: 2,� �/ " ' Date: S111-2 -61/7
FORM: RLAP 06-I6 Page 5 of 5

Operation and Maintenance Plan
Yadkin Valley Sewer Authority
Permit No. WQ007349
In accordance to the requirements set forth in Permit WQ0032855 by the
North Carolina Department of Environmental and Natural Resources using
NCGS 143-215.1 and 143-215.3(a) based on 15A NCAC 02T .1 10, Yadkin
Valley Sewer Authority and Southern Soil Builders, Inc. is implementing this
Operation and Maintenance Plan.
The project manager of the land application event will make sure a daily
check off is performed at the start of each work day. This inspection is to
prevent any spills, leaks, or run-offs.
The daily check -off will consist of inspection the following items:
1. Access to the facility will be controlled with a locked gate and
signs to prevent any unauthorized entry into the complex.
2. All pumps and hose will be checked at the start of each day for
leaks or loose fittings.
3. All tanker valves are closed prior to loading and lids are closed
prior to transport.
4. All dump trailers or dump trucks gates are tightly fastened and
do not leak prior to transport.
5. All on road equipment is check as per DOT regulations for any
safety or mechanical hazards or issues.
b. All equipment is secured at the end of each working day to
prevent any tampering or unauthorized use.
The ORC or back up ORC will inspect the field after each land application
event to make sure all regulations as required by the permit are followed.
Also the project manager at the end of each working day during a land
application event will make sure that all gates if present are closed.
All samples shall be taken as early as possible before the first application
event of the calendar year to make sure the facility is compliance.

The samples will be taken in a matter that is representative of the residuals
and all grab samples will be mixed prior to be placed in to the containers
that will go to the laboratory. These samples must be collected and
transported as outlined in the Sampling Plan attached to this O&M Plan.
All records of these laboratory results as well as the annual report and
loading rates will be kept on file for a minimum of five (5) years.

Yadkin Valley Sewer Authority
Permit No. WQ0007349
SAMPLING PLAN
Annually, if a land application event occurs, grab samples are collected from the sludge holding
tank and digesters. These samples will be combined to form individual grab samples to be sent to a
laboratory for analysis. If a land application event is to occur in the early part of a calendar year (Le.
January or early February) these samples may have to be taken in December so results can be obtained
before the land application event, as some results take 30+ days to receive.
These individual grab samples are collected and tested for fecal coliform analysis, volatile solids
reduction, nutrient analysis, and a TCLP test. These tests will be taken by Southern Soil Builders, Inc. All
samples with the exception of the composite residual sample will be taken to Statesville Analytical. The
composite residual sample will be sent to Waypoint Analytical. All samples taken will be taken in the
same condition as the residuals are to be land applied.
To achieve the vector attraction requirements, A gallon of residuals will be sampled from the
sludge holding tank and analyzed for option 3 503.33(b) (3); known as a 30 day bench scale. This test
requires less than 15% additional volatile solids reduction during bench -scale aerobic batch digestion for
30 days. The results and calculations received from the lab must be confirmed to prevent any human
error in the mathematical calculations of the Van Kleeck formula.
Fecal Coliform are gather in seven (7) individual samples from the sludge holding tank and
tested to meet the requirements of [503.32(b)(2)], This requirement is for the geometric mean fecal
coliform density of the samples be less than two million (2,000,000) MPN per gram. These samples will
be placed in 250ml containers and placed on ice, in a cooler for transport to the laboratory before 1600
hours (4pm) the same day the samples are obtained. These samples will be taken over a minimum of 2
week period in order to represent the performance of the facilities under a range of conditions.
Annually, if land application occurs, a composite residual sample will be collected from the
sludge holding tank and analyzed, prior to a land application event for: Cadmium, Copper, Lead,
Mercury, Molybdenum, Nickel, Selenium, Zinc, Aluminum, Ammonia Nitrogen, Calcium, Nitrate
Nitrogen, Magnesium, % total Solids, pH, Phosphorus, Potassium, TKN, Sodium. From this information,
the Plant Available Nitrogen (PAN) and a Sodium Absorption Ratio (SAR) will be calculated. This sample
will collected in a non -breakable container, at least one quart in size.
A full TCLP test, including corrosivity, ignitability, and reactivity will be taken in two (2) gallon
containers from the sludge holding tank. This test will be run annually, unless prior approval is granted
from the division to reduce this requirement to once per permit cycle.

SPILL CONTROL PLAN- Southern Soil Builders Inc.
YADKIN VALLEY SEWER AUTHORITY
In the event of a spill, the following should be taken IMMEDITALY.
I. Halt the source of the spill- overturned truck, leaking valve, ruptured tank.
2. Contain the spill. Use straw bales or earthen barrier to form a dike to contain the
spill.
3. Cleanup. Employ vacuum trucks, dump trucks, and loaders to remove as much
of the spilled material as possible. Use straw to soak -up the remaining material.
Dispose of the same in a landfill.
4. Flush the roadways with water if needed. If the spill occurred on a tillable area, till
the same into the soil and spread lime if necessary. If a spill occurs on private
property, final clean-up should be to the satisfaction of the owner.
5. Notification. (This should be done as soon as safely possible.)
A. Southern Soil Builders, Inc. Main Office [phone]
B. Yadkin Valley Sewer Authority: Nicole (336)-366-0870
C. NCDENR, Winston-Salem Regional Office [phone]

D. County Emergency Services (Sheriff, Fire Dept.) 911
6. Reporting. The project manager shall detail how the spill occurred and all action
that was taken. A written report shall be given to the Asheville regional office as
soon as possible, and within 24 hours of the spill, or next working day.
7. Spill Prevention. The easiest way to clean a spill is to prevent one.
A. Ensure loading personal watch the vehicle being loaded.
B. Ensure all valves and lids are closed.
C. Inspect all seals and replace if necessary.

DWR State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
INSTRUCTIONS FOR FORM: RSC 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the Applicant shall submit one ori inal and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Uni[
General — This certification provides detailed information of residuals source generating facility and its residuals quality for land
application, distribution, or disposal in accordance with I 5 NCAC 02T .1 100. Do not submit this certification for review without
a corresponding application form (FORM: RLAP 11-15, FORM: DCAR 11-15, or FORM: SDR I1-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Source Certification (FORM: RSC 11-15):
❑ Submit the completed and appropriately executed Residuals Source Certification (FORM: RSC 11-15) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
❑ For new or renewed permits, submit a separate certification for each source facility.
❑ For modified permits, submit a separate certification for only those facilities that are affected by the proposed modification.
❑ Complete the residuals source facility summary page. List all new, renewed, or modified facilities.
B. Residuals Source -Generating Facility Information:
❑ For each source facility, attach the following:
❑ Vicinity map - A vicinity map that shows the location of the facility and meets all of the criteria in the "Map Guidance for
Residuals Land Application Permits".
❑ Process flow diagram and/or narrative - A detailed narrative and/or process flow diagram that describes how the residuals
are to be generated, treated, processed, and stored at the facility.
❑ Quantitative justification for residuals production rate - A quantitative justification for the value provided in Item I. 8.
Ensure that the amount of residuals listed is the maximum amount expected to be generated by the facility for the life of
the permit. In addition, ensure that this amount is equivalent to that which is actually to be land applied, distributed,
and/or disposed, including any chemicals, amendments, or other additives that are added to the residuals during
processing.
❑ Sampling plan - A detailed sampling plan for the residuals source -generating facility. Ensure that the plan identifies
sampling points, sampling frequency, sample type, as well as the Division -certified laboratory to be used. In addition,
ensure that the plan details how the facility and/or the residuals are monitored for any applicable pathogen reduction and
vector attraction reduction requirements. Note that all sampling and monitoring must be completed on the residuals as
they are to be land applied, distributed, and/or disposed.
C. Residuals Quality Information:
❑ For each source facility, attach the following:
❑ Laboratory analytical reports and operational data - reports for all laboratory analyses used to complete this certification.
❑ Documentation that the facility complies and/or the residuals comply with any applicable pathogen reduction and vector
attraction reduction requirements.
❑ For new facility that may have not yet been constructed and analytical results of residuals cannot be obtained, please
attach analytical results of residuals generated from a similar facility along with the description of similarities of the two
facilities.
INSTRUCTIONS FOR FORM: RSC 06-16 Page 1 of I

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DWR State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
1. RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction B.):
1. Facility Name: Yadkin Valley Sewer Authority
2. Facility permit holder is: 0Federal, C] State,
Local Government, or 0 Private.
Facility permit issued by: 0 Div. of Water Resources,
Div. of Environmental Health,
or 0 Other (explain:
3. Facility contact person and title: Nicole Johnston
Complete mailing address: PO Box 828
City: Elkin State: NC
Zip: 28621
Telephone number: [phone] E-mail address: nichole iohnston(n vsa ore
4. Facility physical address: 200 Marion Street
City: Elkin State: NC Zip' 28621
—
Coordinates: Latitude: 360 49' 24_58" Longitude: 80° 49' 57.66_"
Datum: NAD83 Level of accuracy:01
Method of measurement: MAP
5. Purpose of the facility:
treatment of municipal wastewater, 0 treatment of 100% domestic wastewater,
fl treatment of potable water, 0 treatment of 100% industrial wastewater,
0 treatment of industrial wastewater mixed with domestic wastewater,
(approximate percentages: _ % industrial and _ % domestic)
other (explain: ),
6. Does the facility have an approved pretreatment program: Z Yes 0 No
7. Facility permitted/design flow: 1_8 MGD and facility average daily flow: 0.805 MGD
8. Average amount of residuals being generated at this facility 101.8 dry tons per year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment:
Type and volume of residuals storage (i.e., outside of residuals treatment units):
11. RESIDUALS QUALITY INFORMATION (See Instruction C.):
I. Specify if residuals are regulated under:
N 40 CFR Part 503 or 0 40 CFR Part 257.
Note: Only residuals that are generated during domestic/municipal wastewater treatment processes are regulated under 40
CFR Part 503, otherwise, the residuals are regulated under 40 CFR Part 257.
2. Specify if residuals are defined under 15A NCAC 02T 1 102(6) as:
2] Biological 0. Non -Biological
Note: Biological residuals are residuals that have been generated during the treatment of domestic wastewater, animal
processing wastewater, or the biological treatment of industrial wastewater (biological treatment is a system that utilizes
biological processes including lagoons, activated sludge systems, extended aeration systems, and fixed film systems).
FORM: RSC 06-16
Page I of 5

3. Hazardous Waste Determination: Complete the following to demonstrate that the residuals are non -hazardous under
RCRA: (Note - this item does not have to be completed for facilities that are less than 0.5 MGD in design flow that treat
100% non -municipal, domestic wastewater only)
a. Are the residuals listed in 40 CFR §261.31-§261.33: ❑' yes no.
If yes, list the number(s): '_
b. Specify whether or not the residuals exhibit any of the characteristics defined by 40 CFR §261.21-
261.24: 0 yes 0 no.
Fill in the following tables with the results of the latest toxicity characteristic leaching procedure (TCLP) analysis as
well as those for corrosivity, ignitability, and reactivity:
Laboratory: Pacer Analytical and Date of analysis: I-16-18
Passed corrosivity test: 0yes ❑ no. pH: s.u. (2 < pH < 12.5)
Passed ignitability test: 2 yes ❑ no. Flashpoint: 200 °F (> 140°F)
Passed reactivity test: Z yes []no. HCN: ND mg/kg (<250) & HZS: ND mg/kg (<500)
TCLP Parameter
Limit
(mg//)
Result
(mg/1)
TCLP Parameter
Limit Result
(Mg/1) (mg/!J
Arsenic
5.0
ND
Hexachlorobenzene
0.13
ND
Barium
100.0
ND
Hexachloro-1,3-Butadiene
0.5
ND
Benzene
0.5
ND
Hexachloroethane
3.0
ND
Cadmium
1.0
ND
Lead
5.0
ND
Carbon Tetrachloride
0.5
ND
Lindane
0.4
ND
Chlordane
0.03
ND
Mercury
0.2
ND
Chlorobenzene
100.0
ND
Methoxychlor
10.0
ND
Chloroform
6.0
ND
Methyl Ethyl Ketone
200.0
NO
Chromium
5.0
ND
Nitrobenzene
2.0
ND
m -Cresol
200.0
ND
Pentachlorophenol
100.0
ND
o -Cresol
200.0
ND
Pyridine
5.0
NO
p -Cresol
200.0
ND
Selenium
1.0
NO
Cresol
200.0
ND
Silver
5.0
NO
2,4-D
10.0
ND
Tetrachloroethylene
0.7
ND
1,4 -Dichlorobenzene
7.5
ND
Toxaphene
0.5
ND
1,2-Dichloroethane
0.5
ND
Trichloroethylene
0.5
ND
],I-Dichloroethylene
0.7
ND
2,4,5 -Trichlorophenol
400.0
NO
2,4-Dinitrotoluene
0.13
ND
2,4,6 -Trichlorophenol
2.0
NO
Endrin
0.02
NO
2,4,5 -TP (Silvex)
1.0
ND
Heptachlor and its Hydroxide
0.008
ND
Vinyl Chloride
0.2
ND
FORM: RSC 06-16
Page 2 of 5

4. Metals Determination: Complete one of the following tables (i.e., as applicable) to demonstrate that the residuals do not
violate the ceiling concentrations for metals regulated under 15A NCAC 02T .1105.
a. For Distribution/Laird A plication: Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: Waypoint Analytical and Date of analysis: 1-15-18
Parameter
Ceiling
Concentration Limits
(ClassA & ClassB)
(mg/kg)
Monthly Average
Concentration Limits
(Class A Only)
(mg1kg)
Result
(mg1kg)
Arsenic
75
41
5.25
Cadmium
85
39
2
Copper
4,300
1,500
411
Lead
840
300
26.3
Mercury
57
17
0.573
Molybdenum
75
n/a
5
Nickel
420
420
22.3
Selenium
100
100
5
Zinc
7,500
2,800
622
b. For Surface Disposal Unit (landfill): Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory L; and Date of analysis: _
Distance from Disposal
Unit to Boundary to
Closest Property Line
(meters, check one)
Arsenic
(mg/kg)
Chromium
(mg/kg)
Nickel
(mg/kg)
> 0 but < 25
30
200
210
[] > 25 but < 50
34
220
240
>_ 50 but < 75
39
260
270
75 but < 100
46
300
320
0 > 100 but < 125
53
360
390
Q > 125
62
450
420
Result (mg1kg)
FORM: RSC 06-16
Page 3 of 5

5. Nutrient/Micronutrient Determination: Complete the following:
a. Total solids: 3.45 %.
b. Fill in the following table with the results of the latest analyses (i.e., on a dry weight basis) for the following nutrient and
micronutrient parameters:
Laboratory: Wavpoint Analytical and Date of analysis: 1-15-18
eter
Result
o
(mg/kg)
num
51200
Aitrogen
8090
m
10500
ium
381
VPotassium4500
NitrNitrogen
303
PHrd Unit)
6.9
rus
31800
um
4500
Sodium
2580
Total Kjeldahl Nitrogen
43400
c. Using the results listed in Item Il. 5b. above, calculate the sodium adsorption ration (SAR): 1.03
[Note: If residuals contain SAR of 10 or higher, the applicant shall obtain recommendations from the local Cooperative
Extension Office, the Department of Agriculture and Consumer Services, the Natural Resource Conservation Service, a
North Carolina Licensed Soil Scientist, or an agronomist, prior to land application of residuals. The recommendations shall
address the sodium application rate, soil amendments (e.g., gypsum, etc.), or a mechanism for maintaining site integrity
and conditions conducive to crop growth].
d. Specify the mineralization rate to be used in calculating the plant available nitrogen (PAN) of the residuals: 30 %. This
rate is a (check one): Z default value, or ❑ actually established.
If the residuals are not generated from the treatment of municipal or domestic wastewater, explain or provide technical
justification as to why the selected default value is appropriate to be applied to these residuals:
e. Calculate the PAN for the residuals (i.e., on a dry weight basis) and fill the results in rhe fnlln.;n� r u
6. Other Pollutants Determination: Specify whether or not there are any other pollutants of concern in the residuals and provide
the results of the latest analyses: _
FORM: RSC 06-16
Page 4 of 5
o
Application Method
First (111) Year PAN
Five -Year
(mg/kg)
Maximum Adjusted PAN
(mg/kg)
Surface
14941
15986.8
Injection/Incorporation
18986
20315
6. Other Pollutants Determination: Specify whether or not there are any other pollutants of concern in the residuals and provide
the results of the latest analyses: _
FORM: RSC 06-16
Page 4 of 5

Pathogen Reduction: Per 15A NCAC 02T 1106, specify how residuals will meet the pathogen reduction requirements:
a. For Distribution/Laret! Application of Class A or Equivalent..
dA fecal coliform density that is demonstrated to be less than 1,000 MPN per gram of total dry solids,
or
A salmonella sp. density that is demonstration to be less than 3 MPN per 4 grams of total dry solids.
AND one of the followings (except for non -biological residuals):
0 Alternative I [15A NCAC 02T.1106(b)(3)(A)] - Time/Temperature Compliance.
Alternative 2 [ 15A NCAC 02T.I 106(b)(3)(B)] - Alkaline Treatment.
Alternative 3 [15A NCAC 02T.1 106(b)(3)(C)] - Prior Testing for Enteric Virus/Viable Helminth Ova.
Alternative 4 [15A NCAC 02T, 1106(b)(3)(D)] - No Prior Testing for Enteric Virus/Viable Helminth Ova.
Alternative 5 [15A NCAC 02T.1 106(b)(3)(E)-(K)] - Process to Further Reduce Pathogens (PFRP).
Specify one: ❑ composting, [) heat drying, [] heat treatment,
C thermophilic aerobic digestion, ❑ beta ray irradiation,
Q gamma ray irradiation, or ❑ pasteurization.
b. ForLand ApplicationofClass B:
Alternative 1 [15A NCAC 02T.1 106(c)(1)] - Fecal Coliform Density Demonstration.
M' Alternative 2 [15A NCAC 02T.1 106(c)(2)] -Process to Significantly Reduce Pathogens (PSRP).
Specify one: �', aerobic digestion, 0 air drying, 11 anaerobic digestion,
composting, or ❑ lime stabilization.
C. For Surface Disposal:
f Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item 11. 7a. above.
Select One of the Class B or Equivalent Pathogen Reduction Alternatives in Item Il. 7b. above.
El Exempt - If Daily Cover Alternative is chosen in Item 11.8. below [ 15A NCAC 02T. 1106(a)(2)].
0 Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction (VAR): Per 15A NCAC 02T.1107, specify how residuals will meet the VAR requirements:
Alternative
[15A NCAC 02T.1107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
0 Alternative 2 [15A NCAC 02T.1 107(a)(2)] - 40 -Day Bench Scale Test (Anaerobic Digestion).
0' Alternative 3 [15A NCAC 02T.1 107(a)(3)] - 30 -Day Bench Scale Test (Aerobic Digestion).
Alternative 4 [15A NCAC 02T.1 t07(a)(4)] - Specific Oxygen Uptake Rate Test (Aerobic Digestion).
Alternative 5 [15A NCAC 02T.I 107(a)(5)] - 14 -Day Aerobic Processes,
Q Alternative 6 [15A NCAC 02T.1 107(a)(6)] -Alkaline Stabilization.
Q Alternative 7 [15A NCAC 02T.1 107(a)(7)] -Drying of Stabilized Residuals.
Alternative 8 [15A NCAC 02T.I 107(a)(8)] - Drying of Unstabilized Residuals.
[] Alternative 9 [15A NCAC 02T.I 107(a)(9)] - Injection.
Alternative 10 [ 15A NCAC 02T.1 107(a)(10)1- Incorporation.
Alternative for Surface Disposal Units Only - Soil/Other Material Cover []5A NCAC 02T.1 107(b)(2)].
Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
Note: For animal processing residuals, only alternatives 9 or 10 may be chosen due to the nuisance conditions that typically
occur when these residuals are applied and left on the land surface.
FORM: RSC 06-16
Page 5 of 5

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QUANTITATIVE JUSTIFICATION
For the past 8 years the Yadkin Valley Sewer Authority has produced the following Dry Tons
2018 76.61
2017 13.6
2016 118.93
2015 126.46
2014 154.81
2013 11.8
2012 191.91
2011 43.24
This comes out to an eight year average of 92.17 Dry Tons per year. This is well less of the
currently permit amount of 250 dry tons per year. This will allow for any growth in the system or
inflow rates.

Yadkin Valley Sewer Authority
Permit No. WQ0007349
SAMPLING PLAN
Annually, if a land application event occurs, grab samples are collected from the sludge holding
tank and digesters. These samples will be combined to form individual grab samples to be sent to a
laboratory for analysis. If a land application event is to occur in the early part of a calendar year (i.e.
January or early February) these samples may have to be taken in December so results can be obtained
before the land application event, as some results take 30+ days to receive.
These individual grab samples are collected and tested for fecal coliform analysis, volatile solids
reduction, nutrient analysis, and a TCLP test. These tests will be taken by Southern Soil Builders, Inc. All
samples with the exception of the composite residual sample will be taken to Statesville Analytical. The
composite residual sample will be sent to Waypoint Analytical. All samples taken will be taken in the
same condition as the residuals are to be land applied.
To achieve the vector attraction requirements, A gallon of residuals will be sampled from the
sludge holding tank and analyzed for option 3 503.33(b) (3); known as a 30 day bench scale. This test
requires less than 15% additional volatile solids reduction during bench -scale aerobic batch digestion for
30 days. The results and calculations received from the lab must be confirmed to prevent any human
error in the mathematical calculations of the Van Kleeck formula.
Fecal Coliform are gather in seven (7) individual samples from the sludge holding tank and
tested to meet the requirements of [503.32(b)(2)]. This requirement is for the geometric mean fecal
coliform density of the samples be less than two million (2,000,000) MPN per gram. These samples will
be placed in 250ml containers and placed on ice, in a cooler for transport to the laboratory before 1600
hours (4pm) the same day the samples are obtained. These samples will be taken over a minimum of 2
week period in order to represent the performance of the facilities under a range of conditions.
Annually, if land application occurs, a composite residual sample will be collected from the
sludge holding tank and analyzed, prior to a land application event for: Cadmium, Copper, Lead,
Mercury, Molybdenum, Nickel, Selenium, Zinc, Aluminum, Ammonia Nitrogen, Calcium, Nitrate
Nitrogen, Magnesium, % total Solids, pH, Phosphorus, Potassium, TKN, Sodium. From this information,
the Plant Available Nitrogen (PAN) and a Sodium Absorption Ratio (SAR) will be calculated. This sample
will collected in a non -breakable container, at least one quart in size.
A full TCLP test, including corrosivity, ignitability, and reactivity will be taken in two (2) gallon
containers from the sludge holding tank. This test will be run annually, unless prior approval is granted
from the division to reduce this requirement to once per permit cycle.

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SAR
Sodium Absorption Ratio
Na: Sodium (Mg/L) Equivalent weight: 23.
Ca: Calcium (Mg/L) Equivalent weight: 20
Mg : Magnesium (Mg/L) Equivalent weight: 12
Milli Equivalent = Mg/L / Equivalent weight
Na(MI /L Ca M /L M M /L
89.01 362.25 119.02
Na_(ME) C=(ME)3.87 1
The amour
SAR= Na Milli Equivalent/[0.5 X (Ca Milli Equivalent + Mg Milli equivalent)]0.5 power amount of i
r SAR = 1.033732 (From Mg/L entered above) Permitting i
SAR= 1.033747 (From ME entered below)
Na ME Ca (ME) M ME
3.87 18.11 9.92

Analytical Results
Southern Soil Builders
958 Hoots Road
Roaring River, NC 28669
Receive Date: 01/15/2018
Reported: 01/16/2018
For: YVSA
Comments: Geometric Mean 6869 MPN/g
Sample Number Parameter
Sample ID Result Unit Method
180115-na-n� �___, ,. ..-
A —I.-
-
- -
��d Coliforms
1
6785
-
—"O'Yceu
Analyst
180115-04-01
Percent Solids
1
MPN/g
SM92210E-2006
01/15/2018
CL
180115-04-02
Fecal Coliforms
2
3 39
%
SM9221C
01/15/2018
WC
180115-04-02
Percent Solids
2
6949
MPN/g
-200
SM95408-1
01/15/2018
CL
180115-04-03
Fecal Coliforms
3
3
%
97
SM9221C
01/15/2018
WC
180115-04-03
Percent Solids
3
4
MPN/g
SM95408.1 2906
-200
01/15/2018
CL
180115-04-04
Fecal Coliforms
401/15/2018
3.31
3.31
%
SM2540a-199]
WC
180115-04-04
Percent Solids
4
6805
MPN/g
SM92210E-2006
01/15/2018
CL
180115-04-05
Fecal Coliforms
5
3.38
%
SM25408-199)
01/15/2018
WC
180115-04-05
Percent Solids
5
6725
MPN/g
SM92210E-2006
01/15/2018
CL
180115.04-06
Fecal Coliforms
6
3.42
%
SM25409-1997
01/15/2018
WC
180115-04-06
Percent Solids
6
6970
MPN/g
SM92210E-2006
01/15/2018
CL
180115-04-07
Fecal Coliforms
7
3.30
%
SM25408-1997
01/15/2018
WC
180115-04-07
Percent Solids
7
6907
MPN/g
SM92210E-2006
01/15/2018
CL
3.33
%
SM254M1997
01/15/2018
WC
Respectfully submitted,
S1 v,.Y A, J'Yh-�lN
Dena Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 2

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PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 2 of 2

Analytical Results
Southern Soil Builders
958 Hoots Road
Roaring River, NC 28669
Receive Date: 01/15/2018
Reported: 02/20/2018
For: YVSA
Comments:
Sample Number Parameter Sample ID Result
lone, d Unit Method
- - • �dy oencnscaie YVSA
10 % EPA625-R-9210
Respectfully submitted,
007. Vi/a,
Dena Myers a0
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
A
- --- ,,,,a-y,L .
01/15/2018 WC
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 1

-- 461 ounaers
958 Hoots Road
Roaring River NC 28669
Entered: 01/15/2018
Reported: 02/20/2018
Sample ID: 180115-21-01
Volatile Solids Reduction:
Respectfully submitted,
Dena Myers
Statesville Analytical, Inc.
NC WW Cert.# 440NC
DW Cert. #37755
Analytical Results
For: YVSA
0.5451 - 0.5186 X 100 = 10%
0.5451 - (0.5451 X 0.5186)

Analytical Results
Southern Soil Builders
958 Hoots Road
Roaring River, NC 28669
Receive Date: 01/15/2018
Reported: 01/31/2018
For: YVSA
Comments:
Sample Number Parameter Sample ID Result
Unit Method Analyzed Analyst
180115-20-01 TCLP YVSA
See Attached °° Noted 01/28/2018 PACE
Respectfully submitted,
Dena Myers
NC Cart #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 26

aceAnaoical e
w^x'Paco'�be.wm
I
ANALYTICAL RESULTS
Paco Analytical SONIces, LLC
9800 Kincey Ave. Suila 100
Huntarsville, NC 28078
(704)975-90a2
Project: 180115-20
Pace Project No.: 92369723
Sample: 180715.20 Lab ID: 92369723001 Collected; :afriz: Solid
RgSPdl3 reported on a 'd y we/ght- basis and ere edlusted For percent moisture, 01/15/180900 Received: 711 -1617 -,084,`B -M -sample size and any rlllutlons.
Comments: • ChalnOt custody lists matrix as SL; determined to be WT by laboratory
Parameters. Results
Units Report Limit OF
8081 GCS Pesticltles, TCLP -- Prepared Analyzed CAS No. Cual
Analytical Method: EPA 8081 Preparation Method: EPA 351
Leachate MethodlDate: EPA 1311;.01/25/18 14:20
gamma-BHO (Lindane)
Chlordone(Technic 1 NO ug/L
Endrin a)
ND ug/L
0.50 1 01/29/18 08;23 01/29/18 16:11 58.89.9
3'0
Heptachlor
NO ug/L
1 01/29/18 08:23 01/29/713 76:11 57.74-9
0.50 1
Heptachlor epoxide
NO ug/L
01/29/18 08:23 01/29/18 16:11 72-20.8
0,50 1
Methoxychlor
NO u9/L
01/29/18 08:23 01/29/18 1611 76. 8
0.50 1
Toxaphene
ND ug/L
01/29/18 08;23 01/29/18 16;11 10244
10.0 1
Surrogates
NO ug/L
01/29/18 08:23 01/29/18 16:11 72-93-5
3.0 1 -5
Decachloroblphenyt(S)
01/29/18 08:23 01/29/18 16:11 8001-35-2
Talrachloro-m-xylene(8)
50
34 %
10-138 1 01/29/1808:23 01/29/1816:11
8151 Chlorinate Herbicide TCLP
Analytical Method; EPA 8151 Preparation
2051-24.3
/18 0&:23 07/29/18 16:11 877-09.8
2,4-D
Method110 ; 351p
2,4,5 -TP (Silvex)
NO mg/L
NO mg/L
0.31 1 01/23/18 09:31 01/3D/18 12:12 94-75.7
0.31
2,4-DCAA(S)
1 01/23/1809:37 01/30/1872:12 93.72-1
6010 MET ICP, TCLP
85 %
Analytical Method: EPA 6010 Preparation.
39-139 1 01/23/1809:31 01/30/1812:12 19719- 28.9
Leachate Method/Date: EPA 1311;
Method: EPA 3010A
Arsenic
01/18/18 18:15 Initial pH: 6.79; Final pH: 4.5
Barium
Cadmium
NO mg/L
ND m9/L
0.050 1 01/19/1817.25 01/2411813:56 7440.38-2
0,25
Chromium
NO m9/1,
NO
1 01/19/1817:25 01/23/1822:50 7440-39-3
0.0050 1 01/19/1817:25 01/23/1822:50
Lead
Selenium
m9/L
NO mg/L
74404
0,050 1 01/19/18 17:25 01/23/18 22:50 7440-47-3
0.025
Silver
NO mg/L
1 01/19/1817:25 01/23/1822:50
0.10 1 7439-92-1
NO mg/L
01/19/1817:25 01/23/1822:50 7782-
0.025 1
7470 Mercury, TCLP
Analytical Method: EPA 7470 Preparation
01/19/1817:25 01/23/1822:50 7440.22-4
Method: EPA 7470
Leachate Method/Date: EPA 1311;
Mercury
01/18/18 18:15 Initial PH: 6.79; Final pH: 4,5
8270 MSSV TCLP Sap Funnel
NO mg/L
Analytical Method: EPA 8270 Preparation
0.00020 1 01/19/1819:05 07/22/18 11:26 7439-97-6
Leachate Method/Date: EPA 1311;
Method: EPA 3510
1,4-Dichlorebenzana
01/25/18
14:20
2.4-Dinitrotoluane
Hexechloro-1,3-butadiene
NO ug/L
NO ug/L
50.0 1 01/26/1809:40 01/26/1813:16 100-46.7
/L NO ug
/L
50.0 1 01/26/1809:40 01/26/1813:16 121-14-2
50.0
NO ug/L
NO
1 01/26/1809:40 01/26/1813:16 87-
6Hexachloroethane
50.0 1 01/26/18 09:40 01/26/18 13:16
2-Malhylphenol(o-Cresol)
ug/L
NO ug/L
1187q 1
50.0 1 01/26/18 09:40 01/26/18 13:16 67-72-1
3&4-Methylphenol(m&p Gresol)
ND ugA
50.0 1 01/26/1809:40 01/26/1813:16 95-
Nitrobenzene
Pentachlorophenol
NO ug/L
50.0 1 01/26/1809:40 01/26/1813:16 15831704
50,0 1
Pyridine
NO ug/l.100
01/26/1609:40 01/28/1873:18 98-95-3
1
2,4,5 -Trichlorophenol
ND ug/L
NO
01/26/1809:40 01/26/1813:16 87-
50.0 1 01/26/1809:40 01/26/1813:16
ug/L
110-8651
50.0 1 01/26/18 09:40 01/26/18 13:16 95-95.4
REPORT OF LABORATORY
ANALYSIS
Date: 01/30/2018 07:33 PM
This report shall not be reproduced, axcept In full,
without the written consent or Pace Analytical aorvicea, LLC.
Page 5 of 25
PO Box 228 a Statesville, NC 28687 a 704/872/4697
Page 6 of 26

aceAnalgicale
eMM'.p9cWbFrom
Paco Ana lyrical 9ervlces, LLC
9800 K1ncey Ave. Sate 100
Hunleraville, NC 28078
[phone]
REPORT OF LABORATORY ANALYSIS
Date: 01/30/2018 07;33 PM This repos shell not bo reproduced except In full,
without the writlen cons.nt of Pec. Analylicet Services, LOC.
Page 8 of 25
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 7 of 26
ANALYTICAL RESULTS
Project: 180115.20
Pace Project No.: 92369723
Sample: 180115.20
Lab ID192369723001
Lolleoledt 01/15!1809:00 Recelvetl: 01/16/1808:46 Matrix: Solid
Results reported on a 'dry we/pht• bes/sendere ad/usfed.7orpercepf moisture,
Comments: • Chain Of custody flats t moi moisture-
samp/e size
matrix as SL; determined to be WT
and any dilutions,
8270 MSSV TCLP Sep Funnel
.atory
Results Unita RepcA Limit OF
-� __
Prepared Analyzed CAS No.
Analy(IcaI Method: EPA 8270 Preparation
Qua)
Method: EPA 351
Leachate Method/Date: EPA 1311;
2,4,8•Trichlaraphenol
01/25/18 14:20
Surrogates
Nllrobenzene-d6 (5)
NO ug/L 50.0 1
01/26/1809:40 01/26/1813:16 68-06-2
2-Fluorobiphenyl(S)
Terphenyldl4(S)
55 %
63 % 12.102 1 13107
01/26/1809:40 01/26/1813:16 4165.60.0
Phenol-d6(S)
68 % 1
21.132
01/26/1809:40 01/26/1813:16 321-60-8
2-Fluorophanol ($)
19 % 1
10-110 1
01/2611809:40 01/26/18 13:16 1718-51-0
2,4,6-Tribromophenoi(8)
30 % 10-110 1
01/2611809:40 01/26/1613:16 13127.88-3
131
TCLP
54
08 1
01/26/1809:40 01/28/1873:16 124
1316
Benze60 ne
Benzene
Analytical Method: EPA 8260 Leachate Mellhod/Dale: EPA
11849-6
13118019/22118110
2-Butanone (MEK)
NOug/L 100 20
3/78
Carbon tetrachloride
NO ug/L 200 20
01/24/1820:49 71-43.2
Chlorobenzens
NO ug/L 100 20
01/24/18 20:49 76.93-3
Chloroform
NO u9/L 100 20
01/24/18 20:49 56-23-5
1,4 -Dichlorobenzene
NO ugiL 100 20
01/24/1820'49 108.90.7
1,2-Olchloroethene
NO ug/L 100 20
01/24/78 20:49 67.66-3
11-Dlchiorcethene
NO ug/L 100 20
01/24/1820.49 106-46.7
Tetrechlellhanene
NO ug/L 100 20
01/24/1820:49 107-06-2
TrlcM1loroalhene
NO ug/L 100 20
01/24/1820:49 75-35.4
Vinyl chloride
NOug/L 100 20
01/24/1820.49 127-18.4
Surrogates
ND ug/L 100 20
01/24/1820:49 79.01.6
1,2-01chloroethane-d4.(S)01/24/18
20:49 75-01.4
Toluene -d8 (5)
4-Brom0Buorobenzane (S)
99 % 70-130 20
102 k 67.135 20
01/24/18 20:49 17060.07-0
99 % 70-130 20
01/24/1820:49 2037-24
Percent Moisture
Analylloal Method: ASTM 02974-87
01/24/1820:49 460-004
Percent Moisture
1010 Flashpolnt,Closed Cup
96,7
% 0.10 1
Analytical Method: EPA 1010
01/18/18 14.13
Flashpoint
9045 PH $oil
>200 deg F 70'0 1
Analytical Method: EPA 8045
01/18/18 11:50
PH at 25 Degrees C
733C S Reactive Cyanide
y
6.3 Std. Units
0Me 7
Analytical Method: EPA 9014 Preparation
01/18/18 13:50
Cyanide, Reactive
Method: SW -846
7.3.3.2
7348 Reactive Sulfide
NO mg/kg 0'99 1 01/18/18
Analy(Icel MelhotltSM450052F-00
18:09 01/18/1823:40
Sulfide, Reactive
Preparation Method: SW -646 7.3.4.2
NO mg/kg 9.9 1 01/18/1816:09
01/18/1821:37
REPORT OF LABORATORY ANALYSIS
Date: 01/30/2018 07;33 PM This repos shell not bo reproduced except In full,
without the writlen cons.nt of Pec. Analylicet Services, LOC.
Page 8 of 25
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 7 of 26

aceAnalXical ® Pace Analyticel 8.111.1. LLC
e»x'.goe46a.com 9800 Kincey Ave, S,11. 100
HlInterevllle, NC 28078
I
[phone]
ANALYTICAL RESULTS
Project: 180115.20
Pace Project No.: 92369723
Sample: 180715.20,_8
Lab IDr
92369723002
-0ollecled: 01/15/1809:00
Parameters
Received: 01/18/1808:46 Mafriz: Water
Results
units
Report Limit
OF Prepared Analyzed CAS No.
8082 GCS PCB
Analytical Method: EPA 8082 Preparation
oust
PCS -1016 (Aroclor 1016)
Method:
EPA 3510
PCB-1221(Aroclor 1221.)
NO
ug/L
ug/L
5.0
1 01/29/1817:10 01/30/1809:53 12674 -it -2
PCB -1232 (Aroclor 1232)
NO
ug/L
5.0
1 01/29/1817:10 01/30/1809:53 11104.28-2
PCB-1242-(Aroclor 1242)
NO
ug/L
5.0
1 07/29/1817:10 07/30/1809:53 11141-16-5
PCB -1248 (Aroclor 1248)
NO
ug/L
5.0
1 01/29/1617:10 01/30/1809:53 53469.21.9
PCSd254.(Amclor 1254)
NO
5.0
1 01/29/1817:10 01/30/1809:53 12672.29.6
PGB -1260 (Aroclor 1260)
NO
ug/L
ug/L
5.0
1 01/29/18 17:10 01/30118 09:53 11097.69.5
Surrogates
Deoachlorobiphenyl (S)
5.0
1 01/29/1817:10 01/3011809:53 11096. 62-5
20
%
10-132
1 01/29/18 17:10 01/30/18 09:53 2051-24.3
Date: 01/30/2018 07:33 PM
REPORT OF LABORATORY ANALYSIS
This report Shall not be reproduced, except In lull,
wlthoul the written consent o1 Pace Analytical Services, LLC.
Page 7 of 25
PO Box 228 a Statesville, NC 28687 e 704/872/4697
Page 8 of 26

DWR State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources LAND APPLICATION SITE CERTIFICATION
INSTRUCTIONS FOR FORM: LASC 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the Applicant shall submit one original and two covies of the lication and
supoortine documentation
For more information, visit the Water Quality Permitting Section's Nan -Discharge Permittine Unit
General — This certification provides detailed information of receiving sites for land application of Class B residuals (may include
water treatment plant or other type residuals) in accordance with 15A NCAC 02T 1100. Do not submit this certification for review
without a corresponding application form (FORM: RLAP 06-16 or FORM: SDR 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation I isted
below.
A. Land Application Site Certification (FORM: LASC 06-16):
❑ Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ For new or renewed permits, submit the requested information for all land application sites.
❑ For modified permits, submit the requested information for only those sites that are new, transferred or affected by the
proposed modification.
B. Land Application Site Information:
❑ The status of the land application site with respect to this residuals land application program must be provided in table I. The
status categories and their corresponding codes are as follows:
♦ New (N) ♦ Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
❑ Attach the following in accordance with each status code:
Required Item
Status Code
N
R
T
M
[Notfificatbn.doc
✓
-
tll
Land Owner
✓
✓
✓
Agreement
(If applicable)
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Map Guidance
for Residuals_Land Application Permits"
✓
✓
✓
A soils and agronomic evaluation in accordance with the "Soil_ Scientist
Evaluation Policy"
✓
INSTRUCTIONS FOR FORM: LASC 06-16 Page 1 of 3

An updated accounting of the land application site's cumulative
ollutant loadin rates CPLRs ✓
Required Item Status Code
For previously permitted sites without a soil series name indicated in the N R T M
Attachment B, submit County Soil Survey Map (or equivalent) clearly
indicate the location of the land application site and in accordance with ✓ ✓
the soil ma re uirements in the "Soil Scientist Evaluation policy,,
Acknowledgement of field transfer from Land Owner (Fields may not
be ermitted to multi le Permittees over the same time eriod)✓
* This item may be required for land application site with a status code "M", please contact the Division if you need assistant in
determining attachment requirements.
❑ Crop Type should include the most likely crop types for the life of the permit (five years).
❑ Predominant Soils Series Name must be either the name of the soil indicated in Attachment "B" of the existing permit, or
name of the soil series as provided by the licensed soil scientist.
❑ Predominant Soil Mapping Unit or Representative Slope: Either the Soil Mapping Unit or the representative slope of each
site must be provided. The predominant soil-mapping unit must be consistent with the predominant soil series name. Please
note that the soil mapping units are variable between Counties, so care should be taken in properly identifying the correct
mapping unit. If a representative slope is provided, it must be determined accordingly:
❑ For sites previously permitted for use, but do not have an established soil mapping unit (the mapping unit provides
information on both the soil series name and the slope of the soil), the Applicant may determine the representative slope
by using the average slope provided in the County Soil Survey (or equivalent). A soil type with a slope range of 4 - 8%
would have a representative slope of 6%.
❑❑ New Sites to be permitted must have slopes determined as part of the soils report prepared by a licensed soil scientist.
Acceptable methods for determining location coordinates (i.e., latitude and longitude) and their corresponding codes are as
follows:
• Address Matching (ADD) • Digital or Raw Photo Extraction (EXT)
• Aerial Photography with Ground Control (AER) • Geodetic Quality GPS Survey (GEO)
• Cadastral Survey (SUR) • LORAN-C Navigation Device (LOR)
• Conversion from Coordinate Plane (CP)
• Navigation Quality GPS (GPS)
• Conversion from Township-Section-Range (TSR) • Remote Sensing (RS)
• Conversion from Universal Trans MercUTM
( ) Zip Code Centroid (ZIP)
• Map Interpretation by Digital or Manual Extraction (MAP)
C. Waterbody and Classifications Information: (new sites only)
❑ Use an 8.5 by I I-inch copy of the portion of a 7.5-minute USGS Topographic Map to identify the location where the
residuals program activities are planned to occur as well as the closest downslope surface waters as clearly as possible. Each
map portion must be labeled with the map name and number, the identified location, and be of clear and reproducible quality.
❑ Surface water body classifications information may be found at: http://deg.nc.gov/aboiit/divisions/water-
resources/planning/classification-standards/classifications
❑ Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
htto' ll deo. n c. eo v/con tact/reg io na l-offices
❑ General Instructions: There are 17 river basins in North Carolina. Each basin has associated waterbodies with assigned
subbasins, location descriptions, stream index numbers and established classifications.
I. Identify the project area on a 7.5 minute USGS topographical map (an 8.5 x I 1-inch sheet showing the project area
should be submitted with the permit application regardless of whether a Stream classification was completed).
2. Determine the names of all the closest down slope surface waters from the project site. For unnamed tributaries, see
Table I: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream name" as the waterbody name.
3. Open the link htto://deg.ne.gov/about/divisions/water-resources/plannine/classification standards/classifications.
❑ Stream Classification Process: One of the options below may be used depending on the known initial project information.
❑ KNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
L Select proper basin from the List all Waterbodies in Basin sorted report. Sort hydrologically as this will provide
the proper location descriptions if multiple runs.
INSTRUCTIONS FOR FORM: LASC 06-16 Page 2 of 3

2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The tern
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ KNOWN COUNTY WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
I. Select the proper county from the List all Waterbodies in county, hydrologically report.
2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ UNKNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Use the Clickable basin map to hydrologically sorted list report.
2.Click on the approximate project location to bring up the hydrologically sorted list.
3. Locate the name of the identified waterbody (from General Directions) on the list.
4. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
5. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ Notes on index number and unnamed streams:
Unnamed Streams 15A NCAC 02B 0301(i)
❑ Any stream which is not named in the schedule of stream classifications carries the same classification as that assigned
to the stream segment to which it is tributary (at the point of entry) except:
(A) unnamed streams specifically described in the schedule of classifications;
(B) unnamed freshwaters tributary to tidal saltwaters will be classified "C"; or
(C) after November 1, 1986, any newly created areas of tidal saltwater which are connected to Class SA waters by
approved dredging projects will be classified "SC" unless case-by-case reclassification proceedings are conducted.
❑ The following river basins have different policies for unnamed streams entering other states or for specific areas of the
basin:
utaries Entering Other States or for Specific Basin Areas
River Basinnterin .Go—` is or Tennessee shall be classified "C Tr."
esse Rivertering Georgia or Tennessee shall be classified "C Tr." Such streams in the Savannah
oTennesse2Streams
Savannahnage area entering South Carolina shall be classified "B Tr."
na a Areaad
River
tering Tennessee will be classified "B."
iver Basinterin
the State of Tennessee are classified "C."
Broad River Basin
Streams entering South Carolina are classified "C."
New River Basin
Streams entering the State of Tennessee are classified "C."
Catawba River Basin
Streams entering South Carolina are classified "C."
Yadkin -Pee Dee River
Streams entering Virginia are classified "C," and such streams entering South Carolina are
Basin
classified "C."
Lumber River Basin
Streams entering South Carolina are classified "C Sw."
Streams entering Virginia are classified "C." Except that all backwaters of John H. Kerr
Reservoir and the North Carolina portion of streams tributary thereto not otherwise named or
Roanoke River Basin
described shall carry the classification "B," and all backwaters of Lake Gaston and the North
Carolina portion of streams tributary thereto not otherwise named or described shall carry the
Classification "C and B."
Chowan River Basin
Streams entering Virginia are classified "C."
Tar -Pamlico River
All drainage canals not noted in the schedule are classified "C Sw." except the main drainage
Basin
canals to Pamlico Sound and its bas which shall be classified "SC."
Pas uotank River Basin
All drainage canals not noted in the schedule are classified "C."
INSTRUCTIONS FOR FORM•. LASC 06-16 Page 3 of 3

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a

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T.1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the Applicant shall submit one original and two co ies of the application and
supporting documentation
For more information, visit the Water Qualio, Permitting Section's Non -Discharge Permittinn Lni[
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
this agreement for review without a corresponding application form (FOClass B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .I 100. Do not submit
RM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
❑ Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
❑ A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Yadkin Valley Sewer Authorit
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
Special note
(optional)
(no-till/over-seed/
pasture)
BH -01
No
Fescue
Animal Feed
BH -02
No
Fescue
Animal Feed
BH -05
No
Fescue
Animal Feed
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16

1. STIPULATIONS:
I. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease m otherwise permit the use of the land application sic(s) to a third party. the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-D WR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prim to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program.
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terns and conditions of the permit: take necessary leachate, surface water, groundwater, or soil samples during the
term of. and 12 months after termination of, this Agreement.
11. RESTRICTIONS:
I. Appropriate measures must betaken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12 -month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30 -day period following a residuals land application event. Land application
sites that are to be used forgrazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30 -day period following a residuals Ian(] application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for n 14 -month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20 -month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38 -month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12 -month period following a residuals land application event.
III. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T 0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ 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 coinpliance
boundary to the application package)
I&A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID:
residuals land application program; Permit Number W : —downer is currently permitted under another
ning this
agreement, he/she is requesting that the field(s) be rerroved from the previously permitted dresiduals land e land owner bappl cationeprogra m dge that ands transferred
into the new program;_
(Name of the new program)
FORM: LOA 06-16

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, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: Bi
Address: 531 R
/t U II��
City: o9-- K.4tr` State: Nc Zip: 99999
Phone: 33 - 9as -99,11 E-mail address:_
Signature: Date: 1 _
NORTH CAROLINA, W - IOV COUNTY tt
1, the undersigned Notary Public do hereby certify that s3,�
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 �e brvwX 20
Signature and seal: 3 _
i
My commission expires: Ll ` °) Jo 13
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name
Address:
City:
Phone:
Signature: _
Permittee's Certification:
State:
E-mail
Date:
Zip:
1 certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature:
FORM: LOA 06-16
Date: 21111

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the Applicant shall submit one ori inal and two copies of the application and
sporting documentation
For more ln%ormation, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T 1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
❑ Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
❑ A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Yadkin Valle Sewer Authority
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
p
Residuals Source
Special note
(optional)
(no-till/over-seed/
pasture)
BH -03
Yes
Fescue
Animal Feed
BH -04
Yes
Fescue
Animal Feed
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16

I. STIPULATIONS:
I. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit. 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program.
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
PH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nuu'ients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
11. RESTRICTIONS:
I. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12 -month periost following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30 -day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30 -day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14 -month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20 -month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38 -month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12 -month period following a residuals land application event.
III. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T 0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ 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
TTTccsnnn boundary to the application package)
tqA re -defined compliance boundary is not needed f'or this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: fhe land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new Droeram:
(Name of the new program)
FORM: LOA 06-16

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decision
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, throug
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of th
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract o
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreemenl
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement o
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application sites) as specifies
herein.
Landowner name:
Address: _ _315 01(-) i a 1 Ya I I�i2 . d
City: N/d10 State: Yc- Zip: a2OaO
Phone: _���+' 10`'� ' P�'� 1
/ E-mail address;
Signature:(�•-�✓�� Q_ _ 1G
� Dale: _
NORTH CAROLINA, _� 1 I I�. t
COUNTY
I, the undersigned Notary Public do hereby certify that u Gti 1 �
v _
Personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the a s1r� uttrrrrulq//
day of—E-C I•.•.,� \��``�,P knF -'q��
20
Signature and seal:
7 v Notary Public
My commission expires: LL_-01,JQvfny
Lessee's/Operator's Certification; v/pTH CA�U�`'
///Ill it lr llko
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: i l l,,, W;nSon
Address: _ 5 { !] KIP, h
City: carr �• )`;Jd r
Phone: 336 • q qQ e
tg.� Q11,
Signature:
Permittee's Certification:
R
State; M L
E-mail
Zip: g,� 1
Date: a
I certify that I have read this Agreeme/n't and do hereby agree to abide by the stipulations and restrictions as specified herein,
Signing official name: AA
1
Signature:
FORM: LOA 06-16
Date: "? /l / l `l

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T.1 100 — LAND OWNER AGREEM ENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted. the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .I 100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
❑ Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
❑ A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Yadkin Valley Sewer Authority
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Lease
es/no
(Y )
Land Use or
Cropping Patterns
PP g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
JP -01
No
Fescue
Animal Feed
JP -02
No
.Fescue
Animal Feed
JP -03
No
Fescue
Animal Feed
JP -04
No
Tobacco
Tobacco
JP -05
No
Tobacco
Tobacco
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-I6 Papp I v

1. STIPULATIONS:
I. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terns and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application sites) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program.
including an analysis orconstituents ofthe residuals. residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application sitc(s) as required by the permit: copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures must betaken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12 -month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30 -day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30 -day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the and surface shall not be harvested for a 14 -month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20 -month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38 -month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12 -month period following a residuals land application event.
HLALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T 0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: . The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisic
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, throu
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of t
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that 1 have read this Agreeme
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specif
herein.
Landowner name:
Address:
0
Cit 54"( V
Y qj�r r�</� State:
Phone:
E-mail
N� Zip:_
Signature; � l
pp �� Date: �-�'1-aolq
NORT CAROLINA, _ W+ ]V t ( COUNTY
I, the undersigned Notary Public do hereby certify that JU I p
Personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this they t� aput!!unrru
day of I—<br r�
�7 20
Signature and seal;, /tea m Notar
My commission expires: It - q4z)
Lessee's/Operator's Certification:/rrrrr CAR00
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:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State;
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: /v//,C04
Signature:
Date:
FORM; LOA 06-16

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Southern Soil Builders, Hinson Tract - BH -03 & BH -04 N
Property Owned by: Gayle & Patricia Anthony WE
Property Leased by: Billy E & Patsy L Hinson
316 Old 421 Yadkin Rd. Hamptonville, NC S
250 500 750 ft
Parcel: 0600636
Yadkin County, NC Produced: February, 2019
36.2606, -80.9546 North Carolina State Plane, NAD83 Created by: Joseph Jarvis

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Southern Soil Builders, Poindexter Tract - JP -01
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Old Hwy 21. State Road, NC
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Parcel: 494400293197
Surry County, NC Produced: February, 2019
36.3435, -80.8931 North Carolina State Plane, NAD83 Created by: Joseph Jarvis

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Southern Soil Builders, Poindexter Tract - JP -03
James Poindexter
578 Old Hwy 21. State Road, NC
0 250 500 750 1000 ft
Parcel: 1902907 1 1 1 1 1
Wilkes County, NC
36.3431, -80.8973 North Carolina State Plane, NAD83
N
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Produced: February, 2019
Created by: Joseph Jarvis

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