WQ0002096_Modification_1_20210716

Initial Review
Reviewer Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
r Yes r No
Permit Number (IR)* WQ0002096
Applicant/Permittee JOR Enterprises, LLC
Applicant/Permittee Address 240 So Early Station Road, Ahoskie, NC 27910
Is the owner in BIMS? r Yes r No Is the facility in BIMS? r Yes r No
Owner Type Organization
Facility Name Ahoskie Assisted Living WWTF
County Hertford
Fee Category Minor
Is this a complete
application?*
r Yes r No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review bythe hydrogeologist?* r Yes r No
Regional Office
CO Reviewer
Admin Reviewer
Fee Amount $0
Complete App Date 07/16/2021
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Admin
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Rease provide information on the person to be contacted by N B Staff regarding electibnittal, confirmation of receipt, other
.......................................................... electronic surece, aner correspondence.
_ -
Name * Paula G Armstrong
Email Address*
[e-mail]
Phone Number*
2528625665
Project Information
........ ................................................................................................................................................... ......... ......... ... .... ........ ... ... .... .... .... ... ... ... .... .... .... ... .... .... ......... ......
Application/Document Type* r New (Fee Req ui red)
r Modification - Major (Fee Required)
r Renewal with Major Modification (Fee
Required)
r Annual Report
r Additional Information
r Other
O Modification - Minor
C Renewal
C GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
r Residual Annual Report
r Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
r Wastewater Irrigation
r High -Rate Infiltration
r Other Wastewater
r Reclaimed Water
r Closed -Loop Recycle
r Residuals
r Single -Family Residence Wastewater
r Other
Irrigation
Permit Number:*
WQ0002096
Fbs Current Existing permt number
Applicant/Permittee*
JOR Enterprises, LLC
Applicant/Permittee Address*
240 So Early Station Road, Ahoskie, NC 27910
Facility Name *
Ahoskie Assisted Living WWTF
Please provide comments/notes
on your current submittal below.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.*
(Application Form Engineering Rans, Specifications, Calculations, Rc.)
AAL_MinorModPermit_AII_Docs2021 July. PDF 8.74MB
Loload only 1 RCFdocurrent (less than 250Ivt3). Miltiple documents nest be combined into one RJFfile unless file is larger than
upload limit.
* W By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order
and made payable to the North Carolina Department of Environmental Quality
(NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
1401 7 *AIN11
Submission Date 7/16/2021

RPA Healthcare,Ahoskle Assisted Living
Magnolia Memory �Carer Neighborhood
240 S Early Station Road, Ahoskie, NC 27910
Phone #- 252-513-8591 — Fax #' 252'-862--8017
adrn@ahoskieaLcom — [e-mail], —rcc@ahoskieaLcorn — alz@'ahosl<ieal.com
Licepie# HAL-046-020 NPI#..- 11760953558 Provider ID#. 7804340
July 13, 2021
Ms. Podnam Girl
NC Dept of Environmental Quality
Non -discharge Branch
1617 Mail Service Center
Raleigh, NC 27699
RE, Minor Permit Modification Request
JOR Enterprises LLC - Ahoskie Assisted Living
#WQ0002096
Dear Ms., Podnarn Giri.-
We request a Minor Permit Modification to our permit #WQ0002096, We have provided
waivers signed and recorded by our boundary neighbors, advising their acceptance of
changes to the setback limits originally in the permit, All other conditions remain
Unchanged for th!e permit issued 12/18/2020.
Thank you for your assistance and guidance in this matter. Any questions or concerns,
please give me a call 252.,862,560-5
(j 4'wstnq, K,\'W1CDT
Paula G. Armstrong, BSW
Adn"iinistrator

State of North Carolina
Department of Environmental Quality
"R Division ofWal jj(%0jjj.ces
15A NCAC 02T.0500 -- WAqTEWATElt IRRICA"HON SVS'j'F,,)js
Dilvislon of Water Resources INSTRUCTIONS FOR FORM: WMIS il &SUPPORTING DOCUMENTATION
Plalis, stilexifical amid supporting doculnents Shall be prepared in accordance with 1 5,� N("IM" 02 H[ Al 11
I !' q!! (it' llccessary)'j �5 A
021 .0100, 15,A N1( AC 02T B,', N("A( o 700, 0140,don llcincics� avid"'-11'­­---­ 'I—
.!!aL(! Y1j!,!'lcqJ our Jpr.ra trl (s. Failure to
sublinit all required iterris will rjecessitate addil proeessing avid review time.
F-01'17701'C3, information, visit the W,3teUalify Permitting Soctions Non 1) 1 cl )r c� t
Si C
General — When submitting an application to the Water Quallity Permitting Section's Non -Discharge Permitting (.nit,
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 hell) produce a quicker review time and reduce the amount of
requested additional information.
Unless otherwise noted,flag A pj[gants�Liall submit on a ri (10
of jp2r LirL
documentation.
q_
A. Cover Letter (All Application Packages):
List all itel included in the application package, as well as a brief description of the requested permitting action.
B. Applical Fee (Alt New and Major Mo(fification Applicadoll Packages):
Submit a check, money order or electronic funds transfer made payable to: North Carolina Department of
Environl Quality (NCDEQ). The appropriate fee al for new and major modification applications may
Ise found at: Staindard R1e\J(--,oA( PrO
C" Wastewater Irrigation Systems (FORM-, WWIS 06-16) Application (All Application Packages) -
Submit the completed and appropriately executed Wastewater Irrigation ( Systems '
FORM: WWIS 06-16)
application. Any unauthorized content changes to this form shall rest It in the application package being returned,
If necessary for clarity or due to space restrictions, attachments to the application may be made, as long as the
attachrinents are numbered to corresporidto the section and itern to which they refer,
lf Ure Applicant'rype in It
with the l sac lCarohna Se re 11 1 of SL-'d.e,
If the Applicant Type in Item U. is a partnership or d/b/a, enclose a copy of the certificate filed with the Register of
Deeds in the county of bUsiness.
The facility nal in Item 11.1. shall be consistent with the, facility name on the plans, speGificafions, agreernents,
etc.
The Professional Engineer's Certification on Page 12 of the applicafion shall be !signed, sealed and dated by a
No)ih Cayofiria licensqhl ll`npfessionah Eil ineer,
The Applicall Certification an Page 12 of the applicalJon shali be signed in accordance� with 15A !\�CAC 021-
1
%010,6�,Jil Per '15A, NCAC 02T 0 an alternate person may be designated as the signing official if a
delegation letter is provided from a person who meets the criteria in 1 5A NiC`At 021 0106(!,.0,
if this pron
project is for a renewal Wltlrjout modification, use the 11,R)i[
--'r c- Di �(�-, E.l u'-ij E� j r ,
application. , . E�_ "'[ ()P�( --)RU—,—�
D. Property Owlle?,•shi]P Doculnentat.lon (All Application R,.,wkages)„
Per 15A tJCAC 02T -, 0504,(!), the Applicant shall demonstrate they are the owner of all property containing the
Wastewater treatment, storage and irrigation facilities:
Legal documentation of ownership (i,e., US, deed or article of incorporation), or
Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
Written notarized lease agreement that specifically indicates the intended use of the property and has been
signed by both parties, as well as a plat or survey map, Lease agreements shall adhere to the requirements
of 15A NU: AC 02L 0107'.
Provide all agreements, easements, setback waivers, etc. that have a direct impact on the wastewater treatment,
conveyance, storage and irrigation facilities,
INSTRUCTIONS FOR FORM: )VWJS l & SUPPOR'FING DOC I UMENTATION ]"I�c I ol

Soil Evaluation (All Appficaiion Packaues [hat incluclu new irrigation sites):
15A NCAC 02-f' 05 11 and the SrA ScJenflst Evafivatic)�­� P�� flEy, submit a detailed soil evaluation that has
been signed, sea�ed arid dated by a 1'40111f]h
ed ScWi &Jentlst and includes at a rniriirnurn:
The report shall identify all the j�j_teaelds­wit_h­proj - e , of - name, I- location, and induce a staternent that the
sites/fields were recommended for the proposed land application activity.
Field delineated detailed soils map meeting all of the requirements Of the S00 Sciemfist Eva4,mflDri
Soil profile descriptions meeting all of the requirements of the Sod Scientist EvaWefti()�r� ��!Ioik,
Provide all soil boring logs performed at the site, . ...... ____ " Y
Standard soil fertility analysis conducted no more than one year prior to permit application for each rnap unit
in the soil map legend for the following parameters:
EWA
Base sa!Uration (by calculation)
Calcium
Cation exchange capacity
Copper
Exchangeable sodium
calculation)
MagnesiUrn
Manganese
Percent hLIMiC matter
pH
percentage (by Phosphorus
PC)taSSu'Url
Scidiurn
Zinc
Saturated hydraulic conductivity (KcAT) data that shall include at a rninimurn:
A minlrnum of three KSAT tests shall be conducted in the most restrictive horizon for each soil series in the
soil map.
All K,,, tests shall be conducted in areas representative of the site,
All 'tests shah be run until steady-state equilibrium has been achieved.
Ali collected K11T data shall be submitted, including copies of field worksheets showing afl collected
readings,
Submit a soil profile description for each K,,, data point that shall extend at least one foot below the
tested horizon.
Soil evaluation recommendations shall include at a minirriium�
A brief summary of each reap unit and its corriposition and identification of minor contrasting soils.
Maximum irrigation precipitation rate (in/hr) for each soil/map unit within the proposed irrigation areas.
Seasonal irrigation restrictions, if appropriate.
Identification of areas not suitable for wastewater irrigation,.
Recommended geometric mean K,,, rate to be used in the water balance for each soil/map unit based
upon in -situ rneaWrernent of the saturated hydraulic conductivity from the mios,t restrictive horizon.
Recommended drainage coefficient to be used in the water balance based upon comprehensive site:
evaluation, review of collected onsite data, minor amounts of contrasting soils and the nature of the
wastewater to be applied.
Recommended annual hydraulic loading rate (in/yr) for each snail/map unit within the proposed irrigation
areas based upon in -situ K,,- measurements form the most restrictive soil horizon,
NOTE — lf the soil evaluation was performed more than one year prior to the submittal of this application package, a
staternent shallbe included indicating that the site has not changed since tile original Investigation.
Agronomist Fvaluation (All ApiPlicalion Packages 01M ioc�U&,
rl new wrigauon saes or nmv crops Io,- Cirj-ig,Liojj sites):
Pei, 15A NCIAC 02T submit an, agronomist evaluation that has been signed, sealed and dated by a
qualified professional and includes at a minimum:
Proposed nutrient uptake values for each cover crop based upon each field's dominant soil series and
percent slope.
Plant available nitrogen calculations for each cover crop using tile designed effluent concentrations in
Applicafion ltem V.I. and proposed mineralization and volatilization rates.
Historical site consideration, soil binding and plant uptake of phosphorus.
Seasonal irrigation restrictions, if appropriate,
A clear and reproducible map showing all areas investigated and their relation to Proposed fields and crops,
ciMaintenance and Management plan for all specified crops.
fT,,',STR UCTIONS 1701Z F'01M W"WIS 06- 16 &, 'U"O"TNG DOCUM'NTATIO'
J'age 2 of 6

Hydrogeologie Report (All Application flackages treating indlistrial waste or having a CICSigll flow raver 25,000 GPD):
Per 1-56 ilJCAC 02'1'0504_(!�
y
g gjthe Gn�undwater Mo Ming.
and the Perforinmjm�,e alild 1%nMysis q gn� f --8qgjfe�, � sk:�g c t, submit a detailed
hydrogeologic description that has been signed, sealed and dated by a qualified professional and includes at a
minimurn:
A hydrogeotogic description to a depth of 20 feet below land surface or bedrock, whichever is less, A greater
depth of investigation is required if the respective depth is used in predictive calculations.
Representative borings within the irrigation areas and all proposed earthen impoundments.
A description of the regional and local geology and hydrogeology.
A description, based on field observations of the site, of the site topographic setting, strearns, springs and
other groundwater discharge features, drainage features, existing and abandoned wells, rock outcrops, and
other features that may affect the movement of the contaminant plurne and treated wastewater.
Changes in lithology underlying the site.
Depth to bedrock and occurrence of any rock outcrops.
The hydraulic conductivity and transmissivity of the affected aquifer(s).
Depth to the seasonal high water table (SHWT),
A discussion of the relationship between the affected aquifers of the site to local and regional geologic and
hydrogeopogic features,
A discussion of the groundwater flow regime of the site prior to operation of the proposed facility and post
operation of the proposed facility focusing on the relationship of the system to groundwater receptors,
groundwater discharge features, and groundwater -flow media,
If the SHWT is within six feet of the suirface, a mounding analysis to predict the level of the SHWT after
wastewater application.
H. Water Balance (All Application Pack'ages that inchl& riew or rriodified irrigation sites, chanlyus ill flow or changos ill storage):
"T, 4 'l and the �3�cu halatice that has been signe.cl, sealed
ion Po�i submit, a Watel
1---- 1-,,.,- --.— -11-- --.— i,
and dated by a qualified profossional and iticlu(jes, at a inininiurn:
At Jcast a two-year rteraal icwra of data coniputation diat considers prccipitaiior inlay an(i evapor,,11ion lrojjj ,all o,T11
atmosphere storage inipoundirlems, and uses as variable number ofdays per ni(intil.
Prc:Cillitatiorl based on ale 80" lot rccritde and a niininiurn ol'30 years orobserved data.
iriediod, or another approved mediodoh),Ily, LISMg a 111MMILIM
1)CACIltial Kvapoliranspilatioll WFT) using die ThonlijiWaite
of',30 years ofobserved temperature data,
L Soil drainage based on the geonietric '),Carl of the insiloKW ieSIS In the most rest.rictive ilodzon and a drainage
c0efficiclit ranting froni 4 to I 0")(unless Othcrwisc technically docarriented),
Other i'actors that 11lay restrict the hydraulic loading rate when dotornnning a 'A'arey hajanCU illChh]U_
[-1 Depth to the SHWT and groundwater lateral movement that inay ITSUlt ill gl-01-Indwater rnotinding.
-iont limitations word seasonal appliCati011 61TICS to WIS1.11-0, �A��astewaLer in'igHtioll does not exceed agronotilic rates.
Mat
Crop in anageril en t ne(ivi(ies resulting in cessation ofirrigatioll I-o,. crop 1-ClIlcyVal.
WTI` -- Wastewater Irrigation yStejjjS residential lac0ities shall have a rninhimin of 14 days oFwet Avather
Engineering Plans (AII Application 11ackages):
\�C Per 15A IPk(, submit standard size and 11 x 17-inch plan sets that have been slgned, sealed
and dated by a Ncpil,),w Caroflria R�erisearl I�IrofessioriM ErIgjine(fr, and shall include at a minimurn:
Table of contents with each sheet nurnbered.
A general location map with at least two geographic references and a vicinity rnap.
A process and instrumentation diagram showing all flow, recycle/return, aeration, chernicap, electrical and
wasting paths.
Plan and profile views of all treatment and storage units, including their piping, valves, and eqi-Jprnent (i.e.,
pumps, blowers, mixers, diffusers, flow meters, etc.), as well as their dimensions and elevations,
Details of all piping, valves, pumips, blowers, mixers, diffusers, recording de0ces, fencing, auxiliary power,
etc.
A hydraulic profile from the treatment plant headworks to the highest irrigation, point.
The irrigation area with an overlay of the suitable irrigation areas depicted in the Soil Evaluation,
Each nozzle/emitter and their wetted area influence, and each irrigation zone labeled as it will be operated.
Locations within the irrigation system of air releases, drains, control valves, highest irrigation nozzlelerrOter,
etc.
For automated irrigation systems, provide the location and details of the precipitation/soil moisture sensor,
Plans shall represent a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW
ONLY, NOT FOR CONSTRUCTION, etc.) that indicate they are anything other than final specifications,
However, the plans may be labeled with the phrase: FINAL DESIGN - NOT RELEASED FOR
CONSTRUCTION.
rNSTRUCTIONS FOR FORM: WWfS 06-16 & SUPPORTING D00 JMENTA,noN Page 3 of 0

SPeCifications (Ali Application Rackagus):
Per 15A NCAC 9,21 submit specification,-, that have been signed, sealed and dated by a Ncn,th
. .. ....... C'airqfi�ia ��cense(J Profes �ona
and shall include at a minimum:
LJ Table ofContenis Nvith each section/page nurnberct.l.
El Dctailcd S[)ccifications lor each U�catmcrlt/s torage/i n-i gat i On unit, as well ,is all piping-, valves, e(JUipment (i.e., pumps,
Howers, Inixers, diflllscrs, flow nicters., etc.), nozzles/emitter;, pirecipilation/soil nioisturc se� so, app ic,
audiHe' ) I visuaI hiigh water alarrns, liner material, etc. , I I (it i able ,
:1 Site Work (i.e., eardixvork, clearing, grubbing, excavatim" trenching backfillinP,,, cornpacli
� ing, fencing, seeding, etc,')
Matcrials t i.e., concrete, tnasonry, steel, painting, loeffiod of constrUC6011, etc.)
E.- Flectrical (i.e,, control pancls, transfer switches, standby power source, c[c.)
" Mcans for onsurin- qua�ity and in[cority ofthe finished prodUd, including leakage, pre,,;surc and finer tostin&
__j 4", Z�l t,
Specifications shall reprcscnt as completed design and not be labeled with i refinjinary pliruscs 1701REVIEW
ONLY, NOT '70" ('ONSTRU(710N, etc.) fljut indicatc they are anything other than tinal 1-1()wevet, ttle
specifications may be labeled with (lie phrase: F"INAL, DESIGN - NOT R Elf"ASED FOR ("0NS7'R1JCTf0N,.
K. Engineering C.'alculations (All Application Packages):
Per 15A NCAC NJ' 1050!!(t;)Q), submit enghieering calculations that have been signed, sealed and dated by a
North Carofina Ncenseid l`lrofess�onal B i�r) 11-1 rr
j(,j e:�: and shall include at a rrOnimum:
Hydraulic and pollutant loading calcula . ti - o . ns for each treatment Unit dernonstratirlig how the designed effluent
concentrations in Application Item V.I. were determined,
Sizing criteria for each treatment unit and associated equipment (i.e., blowers, mixers, flow meters, pumps,
etc.,).
Total and effective storage calculations for each storage unit,
FriGtion/total dynamic head calculations and system curve analysis for each pump used.
Manufacturer's information for all treatment units, pumps, blowers, mixers, diffusers, flow meters,, irrigation
system, etc.
Flotation calculations for all treatment and storage units constructed partially or entirely below grade.
A demonstration that the designed maximum precipitation and annual loading rates do riot exceed the
recommended rates.
A demonstration that the specified auxiliary power source is capable of powering all essential treatment units.
Site Map (All Application Packages) -
Pet �,5 A N(*A,(' -d s and l l x 17 inc,11 site maps that have been signed, sealed and dated by a
. ... .... submit standai , ize .
North C'andina ficensod flrad/ol t1aeals ssioMll LMd SU vmshall
e,­, and include at a niiniminn'.
A sealed rnap of the s,itc wid, topogj_apjjrC Coo(()Ujifltej'VjjS J-10( e­'Ke_
C eding 10 feet, or 25 pw cen I oftotal sitc refict'and
showing all facility-1-clared 4:1_UCrU1'CS and fences wVidlol the )ANIStCWItcj� tiren Pj,yjent, storage and irjig� ation areas,
i
Fl, Soil mapping units Shown on ad u'ri, atiort sires, g
Ei The location of' all Well"S' (JHCILI(Julp, t"Sa'"C 'Ind Ca)Jjstrnctjon details 'if available), surcanis, and
perennW), springs, lakes, Ponds, and other ovtacc drainage t'eaturcs within 500 foot ofa,11 wastcwatcr trcatment., storage
and irrigation sites,
J Delincatiou of the corlIpliance and rcview, boundaries pet- j 5A Q 107 and 0 10.",, and I5,,\ NVAC 021"
it'applicable.
Ej Setbacks as required by j:A NC, v" ccrf'
1. Site propo-ty bOLITAUI-iCS Within 5,00,fect Of, all wastewater twatn"Cllt. AW-at �e and irrigation sites.
F7 All habitable residences (.)L° Places 0i'llUbliG assen-iWy within 500 feel ofall treaLmerit, ston,,q,,e and irl-ilglatioll sires.
NOTF,' ­ For clarity, aMllfij)le Site naps of,die facility "'Ith cat Sileel 111111011160W, nlay he SUbrnitted.
M, Power Reliability Plan (All Application Packages):
Per 1.5A 021' 050,50), submit clocumenlation of power reEabilily that shall consist of at a rrdnil-num:
An automatically activated standby power- Supply onsite that is capable of powering all essential treatment
units Linder design conditions, OAR
Approval from the Director that the facility:
Serves a private water distribution systern that has automatic shut-off during POWef 'failures and has no
elevated water storage tanks,
Has sufficient storage capacity,that no potential for overflow exists, and
N. Can tolerate septic, wastewater due to prolonged detention,
I INSTRuc.,TIONS FOR F(AM WWIS 06-M S-r SUPPORTIM3 F)0(..,UMENTATK)N PLinge 4 of'()

Operation and Malntenance Plan (All Application Packages);
Per 15A NCAc', Q� F submit an operation and maintenance (O&M) plan en corn pa in all wastewater
treatment storage and irrigation systems that shall include at a minimum a description of:
Operation of the wastewater treatment, storage and irrigation systems in sufficient detail to show what
operations are necessary for the system to function and by whom the functions are to be conducted,
Anticipated maintenance of the wastewater treatment, storage arid irrigation systems,
Safety measures, including restriction of access to the site and equipment,
Spill prevention provisions such as response to upsets and bypasses, including how to control, contain and
remediate.
Contact information for plant personnel, emergency responders and regulatory agencies,
NOTE - A final O&M Plan shall be submitted with the partial and/or final Engineering Certification, required under 15A
1`4CAC 0�2T 0 116, however, a preliminary O&IM Plan shall be submitted with each application package,
C. Residuals Management Plan (All Application Packages with new, expanding or replacement wastewater treatment
systems):
Pe r 1 5A N CA 0 21 01504(Lt and .0508, submit a Residuals Management Plan that shali IIICIUde at a rninirrium:
detailed explanation of how generated residuals (including trash, sediment and grit) will be collected,
handled, processed, stored, treated, and disposed.
An evaluation of the treatment facility's residuals storage requirements based upon the 1*1`18AITIUM arrJiCjpat 'ed
residuals production rate and ability to remove residuals.
A permit for residuals utilization or a written commitment to the Applicant from a Permittee of a Department
approved residuals disposal/utilization program that has adequate permitted capacity to accept the residuals
or has submitted a residuals/utilization program application.
If oil/grease removal and collection are a designed unit process, submit an oil/grease disposal plan detailing
how the oil/grease will be collected, handled, processed, stored and disposed,
NO"I"'E Per 15A NCAC 02T 05015f2), a minimum of 30 days of residual Storage shall be provided,
NOTE - Per 15A
­"­­_­­­ 1j), a written rornmitrinent to the Applicant from a Perrnittee of a Department
approved residuals disposal/utilization program is not required at the tirne of this application, however, it shall be
provided prior to operation of any permitted facilities herein,
NOTE .- If an on -site restaurant or other business with food preparation is contributing wastewater to this systern, an
oil/grease disposal' plan shall be submitted,
P. Additional Documentation:
CCI'Micate W'Pubfic Convenience jmd Necessity (All Application Pickag��_,S f61- PriV,'1tCIY-0W11Cd I'Liblic Utjjlfi(,°j):
I
Per 15A NCAC,,' 02T .011ea( 2)( and _i01­4 ?(L j), provide the Certificate of Public Convenience and Necessity
_(f
from the "Jorflih nruralurtaa ijltjtjes Coinrrtussion demonstrating the Applicant is authorized to hold the utility
franchise for the area to be served by the wastewater treatment and irrigation system, or
Provide a letter from the Noilh (�wofina Ljtiflfies Cort,
thWal& ar�fj Sewer Dk(iskDQ F`Ljb,I�c Staff stating
an application for a franchise has been received and that e service area is contiguous to an existing
franchised area or that franchise approval is expected.
Existing Permit (All Modification Packages)�
E] Subn ii i the most recenity lSSUcct exist] ng peanut.
El ProNlide as list of auy iteins Within thc puntit the Applicant WOUld like the Division to address during tlic pe.til-iit
rtiodification (i.e., corriphancc schULUCS, Permit description, rnonitoting, permit coliclitions, etc.).
Final Environmental Docurrient (All Application Packaoes usim, pUbIjC nionics or lands sub ect to the North Carolina
EnvironmoiaJ 11olicy Act undor IM I,4....1?,c i(, �MOO h) 3)400):
. .. . .. .
oi
Per 15A NCAC 02T (3' 4), submit one Cc py of the environmental assessment and three copies of the
en
fina I environtrital docurnent (i.e., Finding of No Significant Irripact or Record (if Decision),,
Include information on any mitigating factors from the Environmental Assessment that impact the design
and/or constrLIC6011 of the wastewater treatment and irrigation system,
Flood -way Remilation coinplijoirice (AH Applic,atia)jt Flackagcs when: any portion of thc Wastewater Ircatriricrit, storzige and
ill-i�a(ion sysicni is located within the I (fo-yuar -floodplain):
Per 15A NiCAC 02 1 ( ), provide written documentation from all local governing entities that the facility
is in compliance with all loca:I ordinances regarding construction or operation of Wastewater treatment arid/or
disposal facilities within the floodplain.
INSTRI TCTIONS ]'OR FOTW: \VIATIS 06- t 6 & SUPP01,0"ING D(➢CUME NTATRI)N ()('6

PAdditional DOCullientatil (confinued):
Operational Agreements (All Application Pal for 110111 C/1"i Owil Associations Barad F)Cvell of ll to lac:
Ff - 0 - rrle/Pr2peqy Owners'Associations
P�er 15/\ NCAC 012T 011," g), submit the properly executed op�2rafil,-)o ial � 11 E)emler tlOA
02T,( 15(g), Si the proposed or approved Articles of Incorporation Declarations and
Fleri_�A"NC A(",-
By-laws,
!�eveLop�ers of lots to be sold
Per 15A 1\F.AC, 0,2T submit the properly executed 0 ell oil M j;1_ fi E
Th i tell ecl or Endangered A(Itil Species Documentation (All AppliCa,Lion fladwgcs):
Kn si docuntentation l the, Dqjartmenls Mj�x�di
lull
tile
st"'Ce ot� allsence of threatened or endangered aquatic speeje��4 xvithin 1hu boundat- (Ill the
\vas(ewater treaIntentt-a
, sloge and irrigai facihlies. y
i If i facility dirccily in)pacts Such spCCiQS, dus docuaiental sjrl,rjj Ill inforniation On the need roli-perill
corlditions Pursuala to k`�,/'r NUAC 01211 0d i l
Wastemil Chemical All (All Application llacl��jgeql treljti�jg IjIdU�;[I.iaj Waste):
Per I 5A �',JCAC 012 0504(bj, provide a corriplete Division certified laboratory then-flical analysis of the effluent
to be irrigated for the following parameters (For new fal an analysis from a sintilar faciNty's effluent is
acceptable):
Ammonia Nitrog(--iiiiii (NH,,-N) Nitrate Nitrogen (NO,-N) Total Oill Carbon
CAblim pi -I Total Phosphorus
Chernical Oxygen Demand (COD) Phenol Total Trillialornethwies
Chloride SodiUm "Total Volatile Orgal
Compounds
Decal Coliform Sodium Adsorption Ratio (CAR) Toxicity Test Parameters
5-day Biochemical Oxygen Fernand
i Total Dissolved Solids
Magnesium Total Kjeldahl Nitrogen (TKN)
lilli lj�ij 1111111
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service:
1617 m,mf, SINIVCT I " (TINTIN
RALIAl NOR."I'll CAROLINA 27699-1617
TELEPHONE NUVIRFR: [phone]
Bar Courier/5
i 4 E 512 N.,S,U,
RA11AG11 a NORTH CAIl QIJINA T7604
FAX NUA4BER(919)807-6496
INSTRUCTION,ll FOR FORM: Wlv�'IS 06-16,k StTPPORTING DOCTIMENTATION7 Pat,,,c 6 uf"6

State of Noi-th Cat-ohna
De-nt of Eiivili-()nniental Quality
R paifineDivisiou of Watei- Resources
Division of Water Resources 15A NCACO2T.05010 ­ WASTFWATFA IRRIGATION SYST-ENIS
FORIM; WNVIS 0()-[6
L APPLICANT INFORMATION:
1. Applicant's name: JOR Fnkerprises LLC- Ahoskie Assisted Li
2. Appkant type: Individual Corporation X General Partnership Privately -Owned Public
Utility
Federal State Municipal County
3. Signature authority's name: Paula Armstrong_._.__. ­ per 15A 11`qCAC' 0,1' Title: Administrator
4,, Applicant's mailing address: 240 S Early Station Rd
City'. Ahoskie ___ State: NC—.— Zip: 2791
5, Applicant's contact information:
Phone number: 252(332.__) 2292 - Email Address: arrrrstrongmgrnt2@g1VaH.00M_
IL FACILITY INFORMATIOW
1. Faciky name,- Ahoskie Assisted Living_
2. 1 ­ acility status:
1 Facility type: Assisted Living tonne for the aged
4. Facility's physical address: 240 S. Early Station Rd_
City:Ahoskie ___ State: NC Zip: 27910--..-­- County: Hertford
5. Wastewater Treatment F
Datum: Level of accuracy: Method of measurement:
6, USGS Map Name: Please reference current ermit for this information
HL CONSULTANT INFORMATION:
1. Professional Engu'neer:
License Number: Firm:
Mailing address:
City: ­ State:
Z#
Phone number:
Email Address:
2. Soil Scientist: .......
License Number-, Firm:
Mailing address:
City: State-,
Zip:
Phone number:
Email Address:.
1 Geologist:
License Number: Firm:
Mailing address"
City: ­ State;
Z#
Phone nUrnber:
Email Address:
4. Agronomist: __
Firma:
Mailing address:
City: -- State:
Zip:
Phone number: (__)
Email Address:
FORMW WNVIS 06-16 Rige 7 012

IV. GENERAL REQUIREMENT'S - 15A INCAC 02T.0100
1. Application type: New Major Modification X Minor Modification
If a rnodification, provide the existing perrnit nLlnlber: WQOOiD2C)96-,.....---- and most recent iSSUarice date: 12-18-
2020
2Application fee:
3. Does this project utilize public monies or lands? Yes or X No
if yes, was an Environmental Assessment required Linder 15A lqCAC 01 C? Yes or No
------- . .......
If yes, which fusel environmental document is Submitted? Finding of No Significant Impact or Record of
Decision
Briefly describe any mitigating factors from the Environmental Assessment that may impact this facility:
4. What is the status of the -following permits/certifications applicable to the subject facility?
5, Please refer to existing permit: information related to this question,
-�D�—te
S�j mit
PermittiCertification D�—te"' --b-a—te —Permit/ Ce—rtificatio-
1— Rubmitted I-_App d in Number Agency Reviewer �OHec' i ( Eoved
If (9-7
[)aaSa fir
ff-Ti & S e, cfi r in a rita I iolin C"", o r t o l
Plan
\tatkm,o(ide C2/Sec tl(;rini404
-----
Pwl c.,'itre at ii riqet it
unat emeni. Pan
"oN e i, ia r d s 401
Other�
6. What is the wastewater type? Domestic or lridustdal (See 15A NCAC�� 021
Is there a Pretreatment Program in effect? Yes or
No
Has a wastewater chemical analysis been submitted? Yes or
No
I
Wastewater flow: GPD
Limited by: Treatment Storage, Field 1--1ydraulics, Field Agronomics or Groundwater founding
Explain how the wastewater flow was determined I ' 5 " A ' I " IAC 0 ' 2 ' I1 " A 14 or Representative Data
Has a flow reduction been approved under 1 5A NCAC 0 Yes or No
- - ------- - --�L
FORM- WWIS 00-16 Paglc 8 of 12

See 15A,I-NCAC---()I,2T- W- , !41(b)L_ for caveats to wastewater design flow rates (i.e.,
rninimum flow per dwelling; proposed unknown non-residential development uses; public access facilities
located near high public use areas; and residential property located south or east of the Atlantic Intracoastal
Waterway to be used as vacation rentals as defined in G,S 42A.,4).
FORM.- WWIs 06-- l 6 R ito
-c 9 of 12

IV. GENERAL REQUIREMENTS .— " 15A IqCAC, " 02 r -,, "' o ' llo ' o(Continued):
I 0
9. What is the nearest 0-year flood elevation to the facility? __ feet mean sea level, Source:
Are any treatment, storage or irrigation facilities located wi[Wn the I 00-year flood plain? Yes or X No
If yes, which facilities are affected and what rneasures are being taken to protect there against flooding?
If yes, has the Applicant submitted written, documentafion of compliance wftil .lr14'13 Arfide 21 Flail t 6?
Yes or No
10. Has, the Applicant provided docurnentation of the presence or absence of threatened or endangered aquatic
species utilizing information provided by the Department's 111atLWa4 I ier� aqca ["0 MI? Yes or No
I L Does the filcility have o Proposed or cxjsting grojjjj(jwrjtcj, 11jollaoring well netwodc'? Yes or No
If ao, Provide -In cxplau',ltion as to why a well network is not proposed:
ffycs, Complotc the following table (NOTE ­-Tbis table may be oxpcoded foraddifional wells):
Well
"'u
StatUS Lafrittide;' Longitude
Name Gradient Location
PreViOLISly
submitted
Ilrovidc the Collowitig iatiwde and long:itudc coordinate deter-minatioil, infim-niation:
I"'Multil: I.CV6 or accuracy: Method ofineasurernent:
12., If the Applicant is a Privately -Owned Public Utility, has a Certificate of Publlc Convenience and Necessity been
submitted? Yes, No or N/A
E
13,, If the Applicant is a Developer of lots to be sold, has a Dev I e DV) been
submitted?
Yes, No or N/A
'14If the ApplicantHome/Pro�perty Owners' Association, has an Assccadore Op!�, A r eme� t
!j OA been submitted? Yes, No or N/A
15. Dernonstration calf historical considerabon for permit approval -- 1,15A IINi CAC 01l?j
Has the Applicant or, any parent, subsidiary or other affiliate exhibited the following?
a. Has [)cen colmutecj j,)f L�
31vil-011111CIIWI cl-611es 1111der Futloul law or 6-S 143- 2, Yes or bra
13, 11as previously abanclowd ,.i w,,istmvarel,• tl,esjjrjaent facility wiffiout propc,Iy clo,,jijg jjjaj f,, cilily,?
1 Nc
c. Has strap aid civil pellalty,,N,Jjel-e salt rip peals have been Yes or N
ca
d Is, non-oompliallt with ,Ijl existilirg non -discharge peral it, Se [t I ell, en t ligreern en t or order? yes or N
c. His luipaid rinriljal fees inaccordajicc with NCA' 02:T - 'j t 9
. ...... . ..... !�) u� 1�_ _!) )L1L � Yes or No
FOT�M: WWTS m-lf) Page f () of 12

E N I � ,
V. WASTENVATER TR ATMENT FACILITT DESIGN CRITERIA ­ 15A NIC/ `OZTAt,5fli5:
1,, For the follow�ng parameters, provide the estimated influent concentrations and designed effluent concentrations
as determined in the Eng�neering Calculations, and utiflzed in the Agronornic Evaluation and Groundwater
Modeling (if applicable,): Included in the cur -rent permit.
Is flow equalization of at least 25% of the average daily flow provided? Yes or No
Does the treatment facility include any bypass or overflow lines? Yes or, No
If yes, describe what treatment units are bypassed, why this is necessary,, and where the bypass discharges:
4. Are mulflpie pumps provided wherever pumps are used? Yes or No
If no, how does the Appiicant intend on complying with 1 5A IIICA(­ _02T 1Cl5 a5(1�'?
5. Check the appropriate box describing now power reliabifity will be provided in accordance with 15A \11CIM ()2'r
Automatically activated standby power supply onsite capable of powering all essential treatment units; or
Approval from the Director that the facility:
Itasit PriViLle wwer SUPP131 that LMLOW,,LjCal9y Shutsaalt clttrin power Cailuresand does noh.,,on(ain ele)/'ILcd WaLer
storage; : tanks,
Has sufficimt storage capacity that no potemial for ()verflow cxist,.,,�, atratt
Can toterate septic wastcwater clue to prokniged LtUlltic)Jj.
6. If tl,-ie wastewater treatment system is located within the I 00-year flood plain, are there water -tight seals on all
treatment units or a minimurri of two feet protection 'from t[je 1 00-year flood plain elevation? Yes, No or
N/A
7, In accordance with 1 5,rk NCAC (r2'f­ how many days of residuals storage are provided?
8 How does the Applicant propose to prohibit public access to the wastewater treatment and storage facilities?
9. if an does itnhfeluennftlupeunrtnp usrtaptstation
tisiopn art eoft tthhee preosposnecdrifaecriiaty (Le5A., h�/iknC th,e2 wa,s3"te)wate? treatrien, piant bOUndNary)-,pn5No, /A --
1"'o be permitted separately, or N/A,- Gravity fed
M If septic tanks are part of the wastewater treatment facility, do the septic tanks adhere to the standards in 1,1`�A
NCAC 18A 1900? Yes, No or N/A
FORM: WWTS 06- 16 Pa(t-,1'c 1 I of-I2

V. WASTEWATER TREATMENT FACILITY DESIGN CRITERIA —15A NCAC 02T .0505 (continued):
11. Provide the requested treatment unit and mechanical equipment information:
a. PRELIMINARY/ PRIMARY TREATMENT (i.e., physical removal operations and flow equalization):
Treatment Unit
No. of
Units
Manufacturer or
Material
Dimensions fit) !
Spacings (in)
Volume
(gallons)
Plan Sheet
Reference
Specifica
tion
Reference
b. SECONDARY 1 TERTIARY TREATMENT (i.e., biological and chemical processes to remove organics and
nutrients)
Treatment Unit
No. of
Units
Manufacturer or
Material
Dimensions (ft)
Volume
(gallons)
Plan Sheet
Reference
Specificat
ion
Reference
c. DISINFECTION
Treatment Unit
No. of
Manufacturer or
Dimensions {ft)
Volume
Plan Sheet
Specificat
Units
Material
(gallons)
Reference
ion
Reference
If chlorination is the proposed method of disinfection, specify detention time provided: minutes (NOTE —
30 minutes minimum required), and indicate what treatment unit chlorine contact occurs:
If ultraviolet (UV) fight is the proposed method of disinfection, specify the number of banks., , number of
lamps per bank: and maximum disinfection capacity: GPM.
d. RESIDUAL TREATMENT
Treatment Unit
No. of
Units
Manufacturer or
Material
Dimensions (ft)ion
VolumePlan
(gallons)
S
Sheet
Reference
Specificat
Reference
FORM: WWIS 06-16 Page 12 of 12

V. WASTEWATER TREATMENT FACILITY DESIGN CRITERIA —15A NCAC 02T .0505 (continued):
e. PUMPS
Location
No. of
Pumps
Purpose
p
Manufacturer!
Type
Capacity
Plan Sheet
Reference
5pecifica
tion
Reference
GPM
TDH
r. bLUVVt=Kb
No. of Specifica
Location Blower Units Served Manufacturer I Capacity Plan Sheet
s TYpe (CFM) Reference tion
Reference
g. MIXERS
Location
No. of Units Served Manufacturer 1 Power Plan Sheet Specificat
Mixers Type (hp) Reference ion
Reference
h. RECORDING DEVICES & RELIABILITY
No. of
Units
Location
Manufacturer
Maximu
m
Capacity
plan Sht
ee
Reference
Specificat
ion
Reference
i. EFFLUENT PUMP / FIELD DOSING TANK (IF APPLICABLE):
Internal dimensions (L x W x H or 9 x H)
ft ft ft
Plan Sheet
Reference
Specificat
ion
Reference
Total volume
ft3
gallons
Dosing volume
fit3
gallons
FORM: WWIS 06-16 Page 13 of 12

Audible & visual alarms
Equipment to prevent irrigation during rain
events
NTT.
FORM. WWiS 06-16 Pave 14 of 12

EARTHEN IMPOUNDMENTI)ESIGN CRITERIA — 15%, NCOtt AXT0505:
IF MORE THAN ONE IMPOUNDMENT PROVIDE ADDITIONAL COPIES OF THIS PAGE AS NECESSARY.
I . What is, the earthen impoundment type?
2, Storage Impoundment Coordinates (Decirriall Degrees),- Latitude: Longitude:
Daturn: Level of accuracy: Method of measurement:
1 Do any impoundrvents include a discharge point (pipe, spillway, etc)? , e c Yes or No
4. Are subsurface drains present beneath or around the Impoundment to control groundwater elevation? Yes or
No
5. Is the impoundment designed to receive surface runoff? Yes or No
No If yes, what is the drainage area? _ ft', and was thils runoff incorporated into 'the water balance? Yes or
6. If a liner is present, how will it be protected from wind driven wave action?:
7. Will the earthen impoundment water be placed directly into or in contact w4h GA classified groundwater'? Yes
or No
If yes, has the Applicant provided predictive calculations or modeling dernonstrating that Such placement will not
result in a contravention of GA groundwater standards? Yes or No
8. What is the depth to bedrock from the, earthen impoundirrient bottom, elevation? ft
If the depth to bedrock is less than four feet, has the Applicant provided a liner with a hydraulic conductivity no
greater than 1 x "ICI -? crrj/s? Yes, No or N/A
Has the Applicant provided predictive calculations or modeling demonstrating that
surface water or groundwater standards will not be contravened? Yes or No
If the earthen impoundment is excavated into bedrock, has the Applicant provided predictive calculations or
modeling demonstrating that Surface water or groundwater standards will not be contravened'? Yes, No or
N/A
9. It'die calAwn impoundrnent is lined and the mean seasonal high water table is hlurher than the imp(:prindnient hottoull
cJevatiola, how WiH the liner he protected (G,g., hubI1147g, �;TOLMLIIVItCf
0. It',applicable, providc aicspecifleation page ref'crences fbi, the liner installation ,rind (esdng rcquiremcnr ,,;:
1, ft' die eardien impounclnwrft is located wiLlifti die I ()0_yCjr 11(r)()(i plijin, has,,i 111illifflUrl 01'LWO fect ol"protection (i.e., Lop of
embanki-nent (devatrioll to I ffl-ycar flood plain elevation) beci i provided? Yes or No
12. Provide the requested earthen irnpoundr-nent design elements and dimensions:
Earthien Impoundment
Design Elements
Earthen Impoundment Dimensions
Liner type:
—Clay n'thetic
7Un�ined­
OtlKer
Top of embankment elevation:
ft
Liner hydraulic
con du ctiAtL.
x cm/s
Freeboard elevation:
ft
Hazard class;
Toe: of slope elevation:
ft
Designed freeboard:
ft
Impoundment bottom elevation:
ft
Total volurne:
3 gallons
1Vlson, seasonal high water table
Effective volume:
ft" gallons
Embankment slope:
Effective storage time:
days
Top of dam water surface area:
ft,
Plan Sheet Reference:
Freeboard eievation water, surface
area:
ft
Specification Section:
Bottom of impoundment suuFace
area'.
f
NOTE —The eflCCtiVC V01U111C SIU111 be [l]C V0111111C I)CMce" d1c rwo foot ti-ceboard elcvation and the- (1) pump intake pipe
elcvatjow (2) impoundmelit bt)q()j-n cleNq1tiol, or (13) mean seasot)rtl Iligil wjteT- table, w1�1c1level- is Uj(')Se8[ to the two foot
freeboard cicvation.
FORM: WWIS 06-16 Page 15 ot'12

Nit.
FORM: WWIS 06-16 Page 16 of 12

IRRIGATION SYSTEM DESIGN CRITERIA — 15.,A, N(IA C 021"MA05-
1 - Provide the minimum depth to the seasonal high water table vent.._
the irrigation area:
NOTE — The vertical separation between the seasonal high water table and the ground surface shall' be at least
one foot.
2. Are there any artificial drainage or water movement structures (e.g., surface water or groundwater) within 200 feet
of the irrigation area? Yes or No
If yes, were these structures addressed in the Soil Evaluation and/or Hydrogeologic Report, and are these
structures to be maintained or modified?
3, Soil Evaluation recommended loading rates (NOTE — This table may be expanded for additional Soil series):
Field's Recommend Recommend —
Soil Series within Soil ed Loading ed Loading Annual' / Seasonal If Seasonal, list
Series Rate Rate Loading appropriate
months
4. Are the designed loading rates less than or equal to Soil Evaluation recommended loading rates? Yes or
No
If no, how does tVie Applicant intend on cwTlplying WWI '15A IIJC(r 02T 0505tD)?
5, How does the Applicant propose to prohibit public access to the irrigation system?
6. Has the Irrigation system been equipped with a flow meter to accurately determine the volurne of effluent ap�pl:ied
to each field as listed in VII.8,,? Yes or No
If no, how does the Applicant intend on complying wiith I 5A 1'4CAC 02T
7 Provide the required cover crop information and demonstrate the effluent MI be applied at or below agronomic
rates:
Cover Crop Soil Series 11/4 S I o p e Nitrogen Uptake I Phosphorus Upta k--e
a. Specify where the nitrogen and phosphorus uptake rates for each cover crop were oblained:
b. Proposed nitrogen mineralization rate:
c. Proposed nitrogen volatilization rate:
d. Minimum irrigation area from the Agronomist Evaluation's nitrogen balanceft,
e. Minim urn Irrigation area from the Agronomist Evaluation's phosphorus balance: ft
f. MinirnUrn irrigation area from the water balance: ft'd
l"'ORM: WW1 S 06-16 Pao(ie 17 of 12

FORM: WW1S 06-16 Page 18 of 12

N111. IRRIGATION sysTEM DESIGN CRITERIA — 15A NC',A('.02"1-':9M5 (continued )-
8. f,icld information (NOTE - This table may Inc oxpanded foi- additional fijclds)�
Designed Designed
Field Area Don'ditant Loading Loading Waterbod
y Classificat
(acres) soil series Rate Rate Latitude Longitude,, Sj:rea,jj Index ion
No. eo
F
----------- . ......
PI-Ovide the lollowing, latitude and longitude coordimac detuni6ladon ill 16-mmilon:
Duwnl: 1XVC1 01'UCCL11,hCY: Method ol'measuj,erncnt:
l'ov assistance , tfiv Nvatet-bodystl-ealn inclex, numbei- and its asso6aiecl JassificatioU'L1 ll, in8CtiOl1S 111,Ly I)e
C'
downloadedat: Imp:/Alct U, I-OV
)ht I i I,.
Spray Irrigation Design Elements Drip Irrigation Design Elements
Nozzle wetted diameter: ft Emitter wetted area: ft2
dazzle wetted area:
Distance between laterals: ft
Nozzle capacity,- GPM Distance between ft
--�—Oz�ie�---- emitters,:
manufactu rer/mod el Emitter capacity: GPI
Elevation —of highest --ffm �Lte r
nozzle: . ..... ft rn a n u fa cturerknod e 1:
emitter ft
Specification Section: Elevation of highest
Specification Section
1`01ZU WWI S 0()-16 Pago 19 ot'I 2

M111
Fj
SETBACKS —15 IIIMiC AC 1102f'.05016:
1. Does the project comply With all setbacks found in the river basin rules 02B 0200)? Yes or
No
if no, list non -compliant setbacks-
2. Have any setback waivers been obtained in order to, comply with 1 �5A NCAC 1021 5W3 z.!) and �01306(t Yes
or No
If yes, have these Waivers been written, notarized and signed by all parties Involved and recorded with the County
Register of Deeds? Yes or No,
3. Provide the minimum field observed distances (ft) for each setback parameter to the irrigation system and
treatment/storage units (NOTE — Distances greater than 600 feet may be marked N/A):
Irrigation Treatment
Setback Parameter System storage
U n its
Any habitable residence or place of assembly under separate ownership o—rnot lo tie
as art q
maintained f the ect site
�r
Any habitable residence or place of assembly owned by the Permittee to be
maintained as part of the project site
Any private or public; water supply source
Surface waters (streams -- internift-tent —and perennial,
wetlands)
Groundwater lowering rJ!Itches (where the bottom of the ditch intersects the Si--IWT)
Subsurf�.,)ce groundwater lowering drainage systems
........... —
Surface water diversions (ephemeral strearns, waterways, ditches)
Any well with exception of monitoring wells
Any property line
Top of shape of embankments or cuts of two feet or more in vertical height
— — ------- - Any water line from a disposal system
Any swimming pool
Public right of way
Nitrification field
Any building foundation or basernent
Impounded public water sr..ipplies
Public shallow groundwater supply (less than 50 feet deep)
Does the Applicani, intend oil Complying Willi 9 fl/w "CIM, 012T 16ffi,)(Cj in order [o have reduced irrioaJon sediacks io
propery lines? Yes or No Zl
If yes, COMplete the following table by providing the required concentrations as determined in the Engineering
Calculations:
Estimated Influent Designed Effluent , Designed Effluent
Parameter Concentration Concentration Concentration
orrthl aj!! �aeL`flail
Ammonia Nitrogen (NH,-N) rng/L mg/L Mg/L
-Tio—ch—emical 0—xyge--nD—emand
rng/L
mg/L nag/1-
Fecal Coliforn-is per 100 mL per 100 mL
Total Suspended Solids (`leas) mg/L mg/L r-ng/L
Turbidity
NTU
FORM: WWIS 06-16 llag,e 20 of 12

IX, ('OAS'[',,k'LW.� SI'E'I"RE)�l'�14ENI'I)ISI'OS./kL,REQUIR,EN,IENT'S-1.5,%,N("A(1"1QJl,'�'II[1,I),IlG)1):
"I, Is this facility located In a Coastal Area as defined per 15A �JCAQ 02[,1 .04013? Yes or No
For assistance determining if the facility is located within the Coastal Area, a reference map may be downloaded
at" Areas
2, Is this an Interim Treatment and Disposal Facility per '15A l\AC 0Z1 t (X04(g Yes or No
NOTE -- Interim facilities do not include County and Municipal area -wide coflection and treatment systerns.
IF ANSWERED YES TO ITEMS II A, AND IX.2., THEN' LET ITEMS IX.3. THROUGH IX.17.
3. Is equallization of at least 25% of the average daily flow provided? Yes or No
4. Now will noise and odor be controlled`?
5.
- Is an automatically activated standby power source provided? Yes or No
6, Are all essential treatment units provided in duplicate? Yes or No
NOTE --- Per i,)A NCAQ )3,"L (-), essenUal treatment units are defined as any unit associated with the
01 ( J�
wastewater treatment process whose loss Would likely render the facility incapable of rneeflng the required
performance criteria, including aeration units or other main treatment units, clarification equipment, filters,
disinfection equipment, pumps and blowers.
7. Are the disposal units (i.e., irrigationfields) provided in duplicate more than one field)? Yes or No
8. Is there an impounded public surface water supply within 500 feet of the wetted area? Yes or No:
9Is there pubiic shallow groundwater sapply (less than 50 feet deep) w�'thin 500 feet of the wetted area?
Yes or No
10is there a private groundwater supply within 100 feet of the wetted area? Yes or No
11, Are there any SA classified waters within 100 feet of the wetted area? Yes or No
'12. Are there any non -SA classified waters within 50 feet of the wetted area? Yes or No
13. Are there any surface water diversions (i.e,, drainage dilches) within 25 feet of the wetted area? Yes or
co
14. Per the requirements in 1 51A, i"qCAO CbZ-j flow Much green area is provided?
15. Is the green area clearly delineated on the plans? Yes or No
16. Is the wetted area within 2,00 feet of any adjoining properties? Yes, No or N/A
drip irrigation)
17. Does the designed annual loading rate exceed 91 inches? Yes or No
Ff. RM� WWIS 06- l 6, 21 of 12

Professional Engineer's Certification:
—_----._.----attest that this application for
(Professional Engineer's name from Application item Iii.i.)
(Faci I ity name firom Application I LCIII f 1. 1 j
lias been reviewed by rare and is amlrate, conipleLe and COMSiSICIlt With the inCormatiol, sUITHed ia' the Mans, specifications,
en,,ineerinp CUlCUlauons, and all other supporting documentation to the best of my knowledge. I further attest that to die best of my
knowledge the; proposed desi",,n has been prepared in accordance with this application package and its instwoions, as well as all
applicable regulations and statutes. M(hough other- professionals may have developed certain Por-lions cal' ibis subrniiiad package,
h, clusioll oftbese niatcriati
nder nder my signature and scat signifies w that I Ilavc review thiS JnUtCr_jal arld grave judged it to heconsistcrit
will, the proposed design,
NOTE - In accordiaricc with Gencj-ai Statutes 143. 2" V 5 6,?), and fl f: tillk, any person who lmowiiigly makes any E 1w suiturneot,
�q)ruserltation, or certification in any application package shall ho guilty ot'a Class 2 misderneanor, which may include a fine not to
cxcced $10,000, as well as uivi I penal6es up to $25,000 per viointi()rl,
North Carolina Professional Engineer's seal, signature, and date:
Applicant®s Certification per 15A VCAC 02T
I, __ attest that this application for
(Signature Authority's name & title from Application Iterri 1,3.)
(FacHity name from Application Itern 11.1
has been reviewed by me: and is accurate and cornplete to the best of my knowledge,. I understand that any discharge of
wastewater from this non -discharge system to surface waters or the land will result in an immediate enforcement action
that may include civil penalties, injunctive relief, arid/or criminal prosecution. I 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 package 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. I further certify that 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 ail appeals have been exhausted or abandoned, are complianit with any active
compliance schedule, and do not have any overdue annual fees per 'I 5 IItCAC 02 r F . O'l
NOTE — in accordance with General Statutes '14,"I­215J3A and M3­215.03, any person who knowingly makes any false
statement, representation, or certification in any application package shall be gUflty 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
I=
FORM: WWTS 06-16 Pagc 22 of 12

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BOOK 829 PAGE 193(2)
329493 11116ri1111119tlP169f111111
F:70e& 07/06/202 1 t 2:17:32 1"'M
MELAME 1­f STOREY, Recjister of Deeds
1­iERTFORD COWIN, NC
rf\"
State of North Cat-ollina
Depailment of Environmell�-Al Quillity
Division of Watei, Resources
NON -DISCHARGE WAS'"FEWATER SYSITM WAIVER
A(MEEMENIT''M WAIVESE111ACKS AS REQUIRED By
15A NCAC 021'.0506(a), .0506(b),.0606(a),AND X06(a)
"I -Laye-A Askevi (printed nallic), ccrtif� that I an,a at deected owner or all
'Iudwri zed agent o I'the propejiy loc�aed at:.
Address; 244 S. Ear y
Para el No.: 5982­01-9549
otyl- Ahoskie
....... . . . .... s carte: NCB
Zjp(,0&: 279,10
Couniy Hertford
Furthertriore, I ceaif 'y t11,11 I an-i authorized to make decisions regarding this property, and that I do lieteby
agree diat (,he sefl-,),ack distaoces cited bdow be granted to dic Apphc<rn0lerniWee hsted on the fbilowing
page,
I understand the setback i-equilTIMM ts set forth in I SA NC Cry 021'. Foi- the parcel iden tified above,
l c0l'scilt to the r(Alowing reduced setbacks:
cj,lLj�(jj t4) I ro ------- p _"_
Tile requh-ed setback of - 150 ­ feet is reduced tam) _25 j..,jLjes
J'C�et, tjjej.(,�J)W y ajj()Wijjg aSteaW tel- ef It C,
irrigation �or infilti-ation no closer (hall 2 5 feet from my 131-1,ppel-ty jille.
a st v , w
leI 14)"la mrf tat f' allowing wastewater effluent
irripfil I y CC(s) main-palace(s) of assembly,
LVLkstewaler Ll !:cLqnjcqt An!Uit _Orgg_(s U1 L `IrojL�rty , 's
_� kttj�Lt Lmt�k to..L_ c_ _LiLi(�_
'Il(n required see -back of feel is i-educed to ___ -feet, tljcj-ej,)y .jjhowijjg time collsti-1.1clioll of
wastewater treatmen t and storage intuits no doses- than feet ftown my ptop el-ty line.
A wLity�amtrr 'UKLMLn nt! jL�t (111it Setback to Ilaes of Assemly
'The reuh-ed setback of fect is reduced to
feet, thereby allowing tile colls1:1-joctioll 4)f
w-1StcwMV1' treatmenil and storage units! no closer than feet from my t°csidencc or place oif
assembly.
1('4AX id -- Al
FORM� NDWSW 12-20 N1,agyc I of'2

Applicant/Permittee: JOR Enterprises, LLC
Address: 240 S. Early Station Rd.
city. Ahoskie
Permit No.: WQ0002096
Pared No.: 5982-01-4849
State: NC Zip Code: 27910 County: Hertford
NORTH CAROLINA, COUNTY
a Notary Public for �ounty, North Carolina,
do hereby certify that personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the day of cue
3b+11
SEAL
'`�
.,\`,-• "R� •,�� Sign#tureoffNlotaryPublie
My commission exr,)ires
' 44Y
o
Once nt56ized, this forth shall be recorded at the Register of Deeds in the county or counties in
w ich described properties are Iocated. A copy of the recorded waiver shall be sent to the
following address:
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-16.17
FORM: NQWSW 12-20 Page 2 of'2

aoorc 829 PAGE 195 (2)
m �4o. 1111111111111111111111111
Filed: 07/06/2021 12:17:33 PIN
MELANIE H, STOREY, Register of Deeds
HERTFORD County, NC
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTEWATER SYSTEM WAIVER
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), AND .0706(a)
I, J'�' f f_ ~;s-� :�., l ,' `. { (printed name), certify that I am a deeded owner or an
authorized agent of the property located at:
Address: 310 B S. Ep U1 Station Rd. Parcel No.: 5972-91-8552
City: Ahoskie State: NC Zip Code: 27910 County: Hertford
Furthermore, I certify that I am authorized to make decisions regarding this property, and that I do hereby
agree that the setback distances cited below be granted to the Applicant/Permittee listed on the following
page.
I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified above,
I consent to the following reduced setbacks:
® Wastewater Irrigation/Infiltration Setback to Property Lines
The required setback of 150 feet is reduced to 25 feet, thereby allowing wastewater effluent
irrigation or infiltration no closer than 25 feet from my property line.
❑ Wastewater Irrigation/Infiltration Setback to Places of Assembly
The required setback of feet is reduced to feet, thereby allowing wastewater effluent
irrigation or infiltration no closer than feet from my residence(s) or place(s) of assembly.
❑ Wastewater Treatment and Storage Unit Setback to Property Lines
The required setback of feet is reduced to feet, thereby allowing the construction of
wastewater treatment and storage units no closer than feet from my property line.
❑ Wastewater Treatment and Storage Unit Setback to Places of Assembl
The required setback of feet is reduced to feet, thereby allowing the construction of
wastewater treatment and storage units no closer than feet from my residence or place of
assembly.
Signature:'` Date: . °,...
FORM. NDWSW 12-20 Paget of2

Applicant/Percnittee: JOR Enterprises, LLC
Address: 240 S. Early Station Rd.
Permit No.: WQ0002096
Parcel No.: 5982-01-4849
City: Ahoskie State: NC Zip Code: 27910 County: Hertford
NORTH CAROLINA.,UnrAhaMnj)tb-n COUNTY
a Notary Public for WMAWCQ12n County, North Carolina,
do hereby certify that Acy f - , Cjr yqV A P 1 A personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the hday of
SEAL
of Notary Public
My commission expires
Once notarized, this form shall be recorded at the Register of Deeds in the county or counties in
which the described properties are Iocated_ A copy of the recorded waiver shall be sent to the
following address:
Division of Water Resources
Non -Discharge Branch
1617 Mail ,Service Center
Raleigh, North Carolina 27699-1617
•� r1l V
nq
tgoR\
V.
FORM: NDWSW 12-20 Page 2 of 2

BOOK 829 PIIYI'�NAiB4ll1'PCI�(z
329495
Red: 07/061202 1 12: � 7� 34 PM
MELANIE H. STOREY, Regh>ter of Deeds
HERTFORD COLMI�V, NC
r� o, s,
State ol'North Carolina
Department ofEnvii-onmental Quality
Division of Water Resources
NON­D1SCHARC,'E WASTEWA,rER, SYS"I'EM WAIVER
ACm'REEMEN`l­f'0 WAIVE SE'TBACKS AS R.EQUIRED BY
15A NCAC, (l2'1'.0506(a),.0506(b),.0606(,t), AND.0706(a)
A
name), Certify that f an'i a deedecl owner or art
audlorized agent-6 f die, property iocated, at:
AddressS' Early Station Rd, Parccl No.: 5982-03-6071
ckyAhoskie State: NC z i, 1 27910 COLIMY: Her[rr
­­­ - ­­­_ ­__­­ C� 2 ford
I'Lid herni ore, I certify tfiat I am authorized Lo rnakc: decisions regarchng this property, an(rl (hat. I clo hereby
agrce dl� it [Ile sett),ack distances, cited below be granted to fl-te 11stod on dic fbilowing,
page.
I understand: the setback requirernents, set forth in 15A NC.AC 02T', F'orthe pareel identified al)()vc,
I consent to the following reduced sethacks -
filtralion Setbaclic tea I rrvrr ayrgrata
T'he reqUired setback of 150 feet is reduced to 25 feet, theretiy allowing wastewater effluent
irrigation or infiftration no closer thti, 25 feet from my property line.
Waslewater I I tion/Infiltration Setback to Places (A'A
!jmewmer IrrMLa __�Ls� Lip blly
setback of — I feet is, reduce5 to 11-r--.--- feet, the.reby allowing wastewater efiligent
irrigation or hifiltration, 110 C10SN' thall feet from my residence(s) or place(s) of assembly
El Was(ewater '171-eatmerat .111(i Str
or'r w Unit Setback, to Pr(
'Fhe required setback of feet is reduced to, - -- — feet, (bereby allowing the construction of
wastewater treatment anj star'-aIge units' no closer than __._ feet from my properrty liner.
Wastewater 1'reatment aml Stogy ma-9K —Unit Is—etl—mck to —Places of Assembly
]"he required setback of feet is reduced to f� et, thereby allowing the constructio)n of.wastemater treahno�lt a W-S'Corage unit's no closet -",th -5 n feet from my residence or place of
amnibly.
1,
I te:
... ....... / 1-4 Da1
FORM: NDWSW 12-201 Pagc' I ot 2

Apl,)Iic,ii-it/,Ilei-tiiittec:'J,OR Enterprises, LLC
11 1
Adchvss: 240 S. Early Station Rd.
C,ily, Ahoskie
Pc,ntm't Nm: WQ0002096
flaivcJ No.: 5982.-01-4-8491
strata . NC_ _ Zij,) CO(jc 27910 (,,,OL1r1,(Y:,,Herfford
NORTH CIA RO [A CO LI NTY
as Notary Public for Nrt `air. n,
do hereby cerfify Mal Pew so na fly ap pea red: bef'o rein c th is day
and acknowledged the due execution of (fie foregoing i list 1tj ulell 1.
Wit ess iny hand and official seal, this
Is, Orture o NotatV,Public
0 T
Aty commission e.�jyires
Once" otarjy'�d 11,iis forru sha.11 he recorded Lit the Register of Deeds in tl"w counry oi- counties in l V �t P
properties are located. A c�,-)py of the recorded waiver shaH be sent to the
fol
DIViSiO11 CWWWCI� ReSOUrces
, Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina, 27699-1617
F"()RM: ND
Page 2 W'2

BOOK 829 PGE 199 (2)
329496 1�IIJI�NI�'IVk'I111qIIN
He,d, 0710('51262 � 12: 17 35 PM
MELANIE 1-1, STOREY', Rcagister of Deeds
'HER MORID Countv, NC
rf�( gs
State of North Carolina
Depal-hYR,11t a Environmental Quality
Division of Water Resources
NOIN-DISCHARGE WASTEWATER SYSTEM WAIVER,
AGREEMENTTO WAIVF SETBACKS AS REQUIRED BY
15A NCAC 02T.0506(a),.0506(b), �0606(a), AND .0706(a)
- - - (printed nainc), certity (hat I ani i (.Jce(iccl owner Or an
au I(Wized agent, )fthe prcap erLy located at'.
Addrew SEaTjy.StatJqn Rd.
Parccl No.: 597'2-92-3340
cityoskie
Stame :_N.,CZipCo(Ic,: 279,10 C'(Ainty: Hertford
IAINIICTIIIOIC, I ccl-tifY Ulat I wu authorized to 111ake decisions regarding this property, ancl that I (Jo hereby
,10-ec 0-MI the se(k2ck c1l"Stanecs riled t)ciow be grarltc(l to the Applicant/Pennittec ijste,cj (g, tile ti)jj()wijjg
page,
I understand the setback 'T'Quireni ents set ford] in IS NC AC 021'. Foy- tile parcel identified a bove,
[ c011se"t to the 1`611owing reduced setbacks.
jjjjgaqon/hrtftrafion Setback.to ' PrA( (TtIdAlles
L - -
'rime required setback 4vf 15Z ied is reduced to) 25 feet, thereby allowing wastewater efflucylt
irrigatioth or infiltration 110, closer thall, 26 ft
ael. froin My Property fine.
wastewater IrriVI!# _iol!j nt 11tration Setback to I'laces Ass In of e L) ja�
FWrc.4FuWc setback of;_ .. . ... .... tort is I-educffl t() __ feet, thereby allowfig wistewater el"Iluclot
irrigation or 14) Closer than feet froin lily residence(s) Or place(s) of assenably.
Wastewater re TaffilenL 1t .' -IldStoralte es
'nie required setback o m.. feet is reduced to feet, their eby 'allowing, the construction of
wastewater treativient and storage units no doser than ___ feet froln my properly fine,
Wastewater 'Treatrncnt, anq a e ti wlpit Seti),-Ick to Places of AssenIbI
_SLtonj_ _-Y
The required setbalc'k I'M is reduced to fect, thereby allowing Me constructioll (of
Mistelviller trcahl]Qnt and stol-q c Units 114) Closer than
44 fect froin ury residence oi- place (j
Signature: '/' - " , ­­PMWI
g I'" Pate 4L
FORM: NDWSW 12-20 Page of"2

Apl)iic,,,ti-i,l:/Pei-iiiittec:JOR Enterpdses, LLC
Addres,s: 240 S. Early Station Rd,
("Ify Ahoskie,
Perinit No..WQ0002096
[Ives-cel Noz 5982-01-4849
Stai' — NC 21910
-------------
011 NTV
a N(Aary Public for North Carolina,
do hereby certify that'.
V' -somall appeared before ruic thi d y
'(�" I-Ir-I PO y S a
and acknowledged Ifte due execution of the foregoing histrument.
W
C-7 itness my handand official wal, this day of
S�gnatiire qI'Noturuy Public
"� n , � it hi'" W, this f6rm shall he recorded at the RegiStey ()rfDeeds in the county or counties it -I
-which the described properties are located, A copy of* tlrje -eco -ded waiver shaH he sort, t() taut;
foilowing address:
Division, W'Water RCSOLB-CCI,
%Icrra lDischarge Bn,,mch
1617 Mall Service Center
Raleigh, North ("aarolina 27699-1617
FORM: NDWSW t2-20
Page 2 ol'2
ZI

BOOK 829 (2)
329497
Red: a 1 pM
MELAME H. s-roREy ' Raaefiart,s If D,ed,
HERTFORD C01111tv, NC
State of North Cai-olina
Departruent of Environmental Quality
Division of Water Resources
NON.-DISCHARCIE WASTEWATER SYST'EM WAIVER
AGREP',MENTTO WAIVE SETBU AS REOUIRED BY
I
15A NC AND,0706(a)
namo), eertlt fleas 1 an-, Qj deede(f owile,,­ jq
authorize(I agent 61, the PIT)Perty located at-
Ad(fivss: S. Early Statiop Rd.
c'ityarc skie
.. ....... ...... . ...... NC, _zip (.,,o&l 7910
County: -Hertford'
ccrtdl that I am aufliorized to make decisions reg,,jj-(jjjjg this property, "mid 1,
hat I (Io fici-eby
ngree that thesobzicl( distances cited below be grante(j to thc Applicant/Perm4tee listed cm il,c jj)jj()wiajg
pag,v,
I tmderstand the setback requirements set ill 15A NCACO2T. Foi- the parcel identifled above,
l c011se"I to the following, reduced setbacks:
�JO_Pimerty Lines
The required setback, of 1�5�feet is reduced to) 25 feet, thereby Vt8j�(° W, �Mjej_ effl"Coll i"H9,1floll (W infilh-ation no closer than feet from illy Property fine.
E] �LV—aste—ni—ter L11 tumti
The required setback ol, feet is reduced to feet, there bY 1:1110wing W:istewater effluesit
irrigation or infiltration 110 Closer thall 1'ect fh)'" 111Y k'"idClICC(s) M' Phice(s) (of assemWy.
E] Wastet�,alcr
a&aatataeaat aaaaal.slor
fie re(jidred setback og _*­­ ft°ct 's reduced to I`IL�etl t11C'1_c'i)�_M1oW111g the Construction Iff
Wastewater treatment and slorage units no closer theses to fi-oin my proper(y Hne_
ID WastewaterTreatment and Sto
Ilia
'The required WIWI( Of' -7 feet is reduced to __ feet, 4:11creby allowing tile Construction of
wastewater ei ter trtilleiq ajja si�wage units "o closejm I'M fi-0111 MY residence or plaice of
assetubly.
sigmature:
FORM: NDWSW J2-20
11,it-c I ol'2

Appkcantdleni,r i [Lee: JOR Enterprises, LLC
Ackfiv;s: 240 S. Early Station Rd.
Permit No.: WQ0002096
11,arc,cl No: 5982-01-4849
talc. -N-C Zip Codc 27910 Hertford
NORTIT CAROLINA, COUNTY
-y Polk a Notai
oui
do hereby certify 111,al Personallyappeared befive me this ray
and acknowledge(I (lie due exectition of the foregoing instrument.
W
C-17-1 fitness wiry hand and offlicial sea[, this the J__I._IYIIdIIaY
�o
ure q 'Notary Public,
40� V
ki�re , (1�,t,J] i S I fOrm sec hall be recorded at the Register of Deeds in tho county or coujjjj(,rs in
Whicll"'
(Iy&JQ,libed f))-0j)eN:ies Marc, located. A copy of tile recorded waiven- Shall be Sel'O to the
R,)Ijowing�c[cNrew
DM"Jon of Mater Resources
Non-Disch.wgc 13r,111c9i.
617 Mail Service Center
Raleigh, North CM'Ofina 27699­1617
FORM: NIDWSW Q­20

Boop(, P�i�IIiIIIIIN'IEfll�0!I;II
(2)
Fjied 07/06/202 1 1217 37 FIM
MELAME �-I, STOREY, R(,�g�stei of Deeds;
HER,rFORID Countv NC
01,\ R s
State of'North Carolina
Department of Environmental Qualityr
Division of Wate-r JZ(ks0tjrC(,,S
NON-DISC'HARGE WASTENVATER SySr rFm WAjr VER
AGREEMEN 11"J'() WAIVE SETRACKS AS REQUIRED [IV
15A NCAC 021'eta 506(a),0506(b), ,0606(a), AND.0706(a)
Inted certiCy that I ain deeded owner o aaar
pl.
�tcatlar�rrZed 'agent �: f the opwy located at:
Addi-ess: 236 S. Eady
PuM No.: 5982-fit 2-5452
c,,iiy: Ahoskie State� NC 7,1p Code� 27910 county: Hertford
F"Lli-dICT11101-C', I certify th"lir I "JIrn ,:authorize(j to nipke decislons regar(Rj-ig this pmpejty, and that I do hereby
lhal the setback distances cite(i boow tic to the Jiqe(i ol, the I , bflowing
page,
I understand tile setback requirements set f(ajqjj it, 15A WAC (l21% F(W the Pal -cc' idendfied above,
[ consent to) the following rediced setbacks.,
Wns-_war L—hug!_ n-C11—tLa—ILtrr &gk,.Lq P, qjjtLrlv Lgjn
'j, 1, t, -equired Setback of fect is rechiced to facet, thereby allowing wastewt 1- efj
irrigation M- infiltration, 110 CIOSer- than Ceet from my property line,
(o Places cat" , w
me required setback of Ar()o
__ ­­ fe(q, is reduced to: tract, thereby allowing wastew"Iter effluent:
irrigation or i1irlit,%itiol,
luo closer tb ,jtj 375 f(bet from 'try r-esidence(s) or place(s) of
D ivasteamter`r , tnLenl 11-14 Sk Propgrly ines
'J'he required setto-ack of 1ect is reduced to Net, thereby allowing the construction of
wastewater trealment aold storage units no closet-, thall ____ feet Jroui Nny property fille.
F-1 AM�11 cLjCe#:.]:reat no em LILY-] 41 "1, Lu_a'_Jt _Sui Lua—ekto
'11te required sctj).jcj( of ­ feet is reduced 1�() fcct, there - bY 'Ifflowing the construction (or
'10.1olle,lij- and slorage units no closer than
wastcmkter� tr feet Fromn iny residence or place ()t'
assembly
4
pp
FORK NDWSN�` 12'-20 Page I of`2

Apphcant/Punflit,,�- JOR Enterprises, LL.0
Adch-ess. 240 S. Early Station Rd.
(,il,y, Ahoskie
Perrtii[No.: VVQ0002096
Parcel 5982-01-4849
Slate: N . C Zip Codc,� 27910 COU I Ity, Hertford
NORTUCAROLINA,_t,,'�C2.,
ary Public for
a Not, _b"A ounty, Nor
do hereby certify that 1�u -ed be -e me this day
I Al— Personally appew fo i
and acknowledged the due execution offfie fol-egoijAg insti-Ilment.
Wituess my hangfiand offichd seal, this the (lay
4 L
Ay cofymred, 51 oil pires eva Lp L
mm S
r `z e,
ized, (his form shall be recorded at the Register of Deeds in the county ()1, counties ill
wiw, tile described prop(,,,.rtics are located, A copy of' [lie recorded mjivef- shall be sent to the
fi,fllowirig address:
Division of'Water Resolli-ces
Nor)-D'schar� 1, e Bn: I licil
1617 Mail Service C'ei-qej.
Raleigh, North ("arohna 27699-1617
Ott-1
,00
F�3
FOlM NDWSW 12-20 i'l,ra
Pagc 2 ol'2