WQ0013921_Renewal Application_20211221

Non -Discharge Branch Upload/Submittal Form
NORTH CAROLINA
EnWrvnmemfal Qualify
Version 2 - Revised June 23, 2020
Initial Review
Reviewer
Thornburg, Nathaniel D
Is this submittal an application? (Excluding additional information.)*
Yes No
Permit Number (IR) * WQ0013921
Applicant/Permittee Murphy -Brown LLC
Applicant/Permittee Address P.O. Box 856, Warsaw, Nc 28398
Is the owner in BIMS? Yes No Is the facility in BIMS? Yes No
Owner Type Organization
Facility Name Rainbow Trailer Wash
County Duplin
Fee Category Minor Fee Amount $0
Is this a complete application?*
Yes No
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review by the hydrogeologist?*
Regional Office
CO Reviewer
Admin Reviewer
Yes No
Complete App Date 12/21/2021
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
Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence.
Name*
Kevin Weston
Email Address* Phone Number*
[e-mail] 9102935363
Project Information
Application/Document Type *
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
Residual Annual Report
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.deg.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type: *
Wastewater Irrigation
Other Wastewater
Closed -Loop Recycle
Single -Family Residence Wastewater
Irrigation
Permit Number:* WQ0013921
Has Current Existing permit number
Applicant/Permittee *
Murphy -Brown LLC
Applicant/Permittee Address* P.O. Box 856, Warsaw, Nc 28398
Facility Name* Rainbow Trailer Wash
High -Rate Infiltration
Reclaimed Water
Residuals
Other
Please provide comments/notes on your current submittal below.
In Section Ill -Flow Information, the application asks for the permitted flow to be shown as GPD
and our current permit is written as GPY (gallons per year, based on a 12-month floating total).
We would like to keep it as GPY as it is in current permit.
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 Plans, Specifications, Calculations, Etc.)
WQ0013921 Rainbow TW WWIS-R-02-21 RenewApp
122121.pdf
Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger
than upload limit.
3.3MB
* 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
Submission Date 12/21/2021

State of North Carolina
Department of Environmental Quality
Division of Water Resources
DWR
Division of Water Resources 15A NCAC 02T .0500 — WASTEWATER IRRIGATION SYSTEM — RENEWAL
FORM: WWIS-R 02-21
Pursuant to 15A NCAC 02T .0107(b), if the application does not include all required information and the necessary supporting
documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02T .0500, and Division Policies. For more information, visit the Water Quality Permitting
Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments
uploaded as a single Portable Document Format (PDF) file to https://edocs.deci.nc.2ov/Forms/NonDischar2e-Branch-Submittal-
Form-Ver2, or emailed to Non-Discharge.ReportsQncdenr.gov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1. Applicant: Murphy -Brown, LLC
2. Permit No.: WQ0013921
3. Signature authority: John Sargent Title: Exec. Vice President
Phone number: [phone] Office Email: [e-mail]
4. Mailing address: P.O. Box 856
City: Warsaw
State: NC Zip: 28398-
5. Contact person: Kevin Weston Email: [e-mail]
Primary phone number: [phone] Office Secondary phone number: [phone] Cell
SECTION II — FACILITY INFORMATION
I. Physical address: 1258 Lanefield Road
City: Warsaw
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 34.947980°
County: Duplin
State: NC
Longitude: -78.29840° Method: Select
Parcel No.: 01-2356
Zip: 28398-
SECTION III — FLOW INFORMATION
1. Permitted flow: 3436 GPD (The maximum allowable flow based on what has been permitted)
2. As -built flow: 3436 GPD (The maximum allowable flow based on what has been constructed)
3. Average flow: 2408 GPD (The average of all reported flows on the previous calendar year's NDMRs)
14. Hydraulic capacity: 70 % (Divide the average flow in Item 3 by the As -built flow in Item 2)
5.
Wastewater composition: Domestic : % Industrial:
Stormwater: %
SECTION IV — BILLING INFORMATION
1. Billing address: P.O. Box 856
City: Warsaw
State: NC Zip: 28398-
2. Verify the Applicant does not have any overdue annual fees:
https://deq.nc. gov/about/divisions/water-resources/water-resources-perm its/wq-epayments
Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: WWIS-R 02-21 Page I of 6

SECTION V — OPERATOR IN RESPONSIBLE CHARGE (ORC) INFORMATION
I. ORC: James Derek Brown
Mailing address: P.O. Box 856
City: Warsaw
Phone number: [phone] Cell
Grade: SI Certification No.: 27678
State: NC Zip: 28398-
Email: [e-mail]
2. Back -Up ORC: Michael Leon Norris
Mailing address: P.O. Box 856
City: Warsaw
Phone number: [phone] Office
Grade: SI Certification No.: 23931
State: NC Zip: 28398-
Email: [e-mail]
SECTION VI — OPEN -ATMOSPHERE STRUCTURES
1. List all open -atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if
necessary.
Type
Parcel No.
Volume (gal)
Liner Type
Freeboard (ft)
Latitude
Longitude
Treatment/Storage
01-2356
318,558
Full, clay
2
34.947986°
-78.29837°
Select
Select
a-
°
Select
Select
G-
°
Select
Select
0-
SECTION VII — RELATED PERMITS
1. List all wastewater permits (i.e., sewer, collection system, NPDES, residuals) that have interactions with the renewing permit.
Attach additional sheets if necessary.
Permit Type
Permit No.
Relationship Type
Select
Select
Select
Select
Select
Select
Select
Select
SECTION VIH — MONITORING WELLS
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Location
Latitude Longitude
WS-1
01-2356
Active
Select
Select
- °
Select
Select
Select
e. - 0
Select
Select
Select
- . °
Select
Select
Select
° - 0
Select
Select
Select
° - 0
Select
Select
Select
° - 0
Select
Select
Select
° - 0
Select
Select
Select
° - 0
Select
Select
Select
° - . -
Select
Select
Select
° - .
Select
Select
Select
- °
FORM: WWIS-R 02-21
Page 2 of 6

SECTION IX — IRRIGATION FIELDS
1. List all irrigation fields associated with the renewing permit. Attach additional sheets if necessary.
Field
County
Parcel No.
Deeded Owner
Area
Cover Crop
Latitude Longitude
01A
Duplin
01-2356
Brown's Realty Partnership
3.25
Bemtuda/Overseed
34.948815°-78.31104°
OIB
Duplin
01-2356
Brown's Realty Partnership
2.80
Bermuda/Overseed
34.947900°-78.32005°
0 °
°
0
° 0
° 0
0
0
0
0 0
0 0
° 0
° 0
° 0
0
0
0 °
0 0
0 0
0
0
0
0
0
0
°
° 0
° 0
Total Acreage:
6.05
FORM: WWIS-R 02-21
Page 3 of 6

ATTACHMENT A — SITE MAP
Was the facility originally permitted or had a major modification issued after September 1, 2006?
❑ Yes — Pursuant to 15A NCAC 02T .0105(d), submit a site map pursuant to the requirements in 15A NCAC 02T .0504(d). These
requirements are:
El A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and showing
all facility -related structures and fences within the wastewater treatment, storage, and irrigation areas.
❑ Soil mapping units shown on all irrigation sites.
❑ 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 all wastewater treatment, storage.
and irrigation sites.
❑ Delineation of the compliance and review boundaries per 15A NCAC 02L .0107 and .0108, and 15A NCAC 02T .0506(c)
if applicable.
❑ Setbacks as required by 15A NCAC 02T .0506.
❑ Site property boundaries within 500 feet of all wastewater treatment, storage, and irrigation sites.
❑ All habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
® No — Skip Attachment A.
AUTHORITY1 s
Does the signature authority in Section I, Item 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)?
® Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
ATTACHMENT C — FLOW REDUCTION
Does the existing permit include an approved flow reduction?
❑ Yes — Submit a copy of the flow reduction approval letter, as well as the measured monthly average amount of wastewater flow
contributed per unit for the 12 months prior to permit renewal. If any of these monthly averages are within 20% of the approved
flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the requirements in 15A
NCAC 02T .0114(f).
® No — Skip Attachment C.
ATTACHMENT D — CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
Is the Applicant a Privately -Owned Public Utility?
❑ Yes — Pursuant to 15A NCAC 02T .0115(a)(1), submit the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise.
® No — Skip Attachment D.
ATTACHMENT E — OPERATIONAL AGREEMENT
Is the Applicant a Home/Property Owners' Association or Developer of Lots to be Sold?
❑ Yes (Home/Property Owners' Association) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement
(FORM: HOA). Pursuant to 15A NCAC 02T .0115(c), if the applicant is a legally formed Homeowners' or Property Owner's
Association, submit a copy of the Articles of Incorporation, Declarations, and By-laws.
❑ Yes (Developer of Lots to be Sold) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement
(FORM: DEV). Pursuant to 15A NCAC 02T .0115(b), if the applicant is a developer of lots to be sold, submit a copy of the
Articles of Incorporation, Declarations, and By-laws.
® No — Skip Attachment E.
FORM: WWIS-R 02-21
Page 4 of 6

ATTACHMENT F — DEMONSTRATION OF FUTURE WASTEWATER TREATMENT CAPACITIES
Is the applicant a municipality, county, sanitary district, or public utility?
❑ Yes — Proceed to the next question.
.I No — Skip Attachment F.
Does the hydraulic capacity in Section III, Item 4 exceed 70%?
❑ Yes (the hydraulic capacity is greater than 70%, but less than 80%) — Pursuant to 15A NCAC 02T .0118(1), prior to exceeding
80 percent of the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee
shall submit an engineering evaluation of their future wastewater treatment, utilization, and disposal needs. This evaluation shall
outline plans for meeting future wastewater treatment, utilization, or disposal needs by either expansion of the existing system,
elimination or reduction of extraneous flows, or water conservation and shall include the source of funding for the improvements.
If expansion is not proposed or is proposed for a later date, a justification shall be made that wastewater treatment needs will be
met based on past growth records and future growth projections, and as appropriate, shall include conservation plans or other
measures to achieve waste flow reductions.
❑ Yes (the hydraulic capacity greater than 80%) — Proceed to the next question.
❑ No — Skip Attachment F.
If answered Yes above, does the hydraulic capacity in Section III, Item 4 exceed 80%?
❑ Yes (the hydraulic capacity is greater than 80%) — Pursuant to 15A NCAC 02T .0118(2), prior to exceeding 90 percent of the
system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee shall obtain all
permits needed for the expansion of the wastewater treatment, utilization, or disposal system and, if construction is needed,
submit final plans and specifications for expansion, including a construction schedule. If expansion is not proposed or is proposed
for a later date, a justification shall be made that wastewater treatment needs will be met based on past growth records and future
growth projections, and as appropriate, shall include conservation plans or other specific measures to achieve waste flow
reductions.
❑ No — Skip Attachment F.
ATTACHMENT G - EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
❑ Yes — Skip Attachment G.
❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation system on
property not owned by the Permittee.
ATTACHMENT H - AFFILIATIONS
Are the Permittee's affiliations of record correct? Check affiliations.
❑ Yes — Skip Attachment H.
• No — Provide the corrected affiliations and their contact information.
ATTACHMENT I — COMPLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section 1 of the most recently issued permit)
❑ Yes — Submit documentation that the compliance schedules have been met.
® No — Skip Attachment I.
ATTACHMENT J — CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Does the Permittee have any existing civil penalties or outstanding violations?
❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request.
❑ Yes (violations) — Submit a copy of your response to the Notice of Violation.
® No — Skip Attachment J.
FORM: WWIS-R 02-21
Page 5 of 6

ATTACHMENT K —INDUSTRIAL WASTEWATER
Does the wastewater composition in Section III, Item 5 include any industrial wastewater?
❑ Yes — Proceed to the next question.
® No — Skip Attachment K.
Has the nature of the industrial wastewater changed since the last permit issuance (i.e., changes in industrial process, introduction of
new materials or chemicals, etc.)?
❑ Yes — Provide a chemical analysis of the wastewater pursuant to the requirements in 15A NCAC 02T .0504(h). Provide an
overview of the manufacturing process; an inventory of all chemical and biological materials used in the manufacturing process;
and an overview of the cleaning and treatment methodology.
❑ No — Provide an overview of the manufacturing process; an inventory of all chemical and biological materials used in the
manufacturing process; and an overview of the cleaning and treatment methodology.
ATTACHMENT L — SETBACK WAIVERS
Does the existing permit include setback waivers?
® Yes — Pursuant to 15A NCAC 02T .0506(d), provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with 15A NCAC 02L .0107.
❑ No — Skip Attachment L.
APPLICANT'S CERTIFICATION
I, �oHrt 5,4 R GENT attest that this application
(Signature authority's name as noted in Section I, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I 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 as incomplete. 1 further certify pursuant to 15A NCAC 02T .0120(b), that the applicant, or any
parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under; not previously abandoned
a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance
schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The App ' ant's Certification shall be signed pursuant to 15A NCAC 02T .0106(b). An alternate person may be delegated as
the signing of i ial a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215.6A and § 143-215.6B, any
person who kno ingl a �s any false statement, representation, or certification in any application package shall be guilty of a Class
2 misdemeanor, w ich n ude\a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
lz�2i�2(
Signature:
Date:
THE COMPLETED APP CATION ND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discharge.Reports(u�ncdenr.gov
Laserfiche Upload:
https://edocs. deq. nc.2ov/Fo rm s/NonDischa rge-Branch-
Submittal-Form-Vert
FORM: WWIS-R 02-21
Page 6 of 6

WQ0013921
Permit Number:
Wastewater Irrigation
Rainbow Trailer Wash
1258 Lanefield Road
Warsaw, NC 28398
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III IIIIIIIIIIIIIIIIIIIIIIIII1I1111
Doc No: 10012751
Recorded: 06/07/2017 09:01:17 AM
Fee Amt: $26.00 Page 1 of 2
Duplin County North Carolina
Davis H. Brinson, Register of Deeds
BK 1860 PG 1000 -1001 (2)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
STATE OF NORTH CAROLINA
COUNTY OF DUPLIN
This Instrument has been filed for
Registration on the Date, Time and in the
Book and Page shown on the First Page
hereof, and is being returned for
your safekeeping.
a
O.
Davis H. Brinson, Register of D ¢J.s
NON -DISCHARGE WASTWATER SYSTEM WAIVER
I,
Address:
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
Bizzell Johnson Davis , certify that I am a deeded owner of the property located at:
Parcel No.: 01-2357
City: State: Zip Code: County: Duplin
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.
St I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from 150 feet to 25 feet, thereby allowing the
application of wastewater effluent as near as 25 feet from my property line.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
application of wastewater effluent as near as feet from my residence.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as _ feet from my property line.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as feet from my residence.
Signature:
FORM: NDWSW 03-17 Page 1 of 2
.........-
Date: 4 -I"

Applicant/Permittee: Murphy -Brown, LLC
Address: P.O. Box 856
Book 1850
Page 1001
(W00013921)
Parcel No.:
City: Warsaw State: NC Zip Code: 28398 County: Dupiin
NORTH CAROLINA, lr� COUNTY
[, tNif-0, C/1nrs , a Notary Public for �.y County, North Carolina,
do hereby certify that tZZ-c.11 10 r\v o 1S 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 fit , alb 14.
„P �SG ;‘CHq��
SEAL
GA o°SLAG
,`C,.``�.
n%N
Signature of Notary Public
My commission expires COI • 15, HOC
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded
waiver shall be sent to the following address:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDWSW 03-17
Page 2 of 2

III IIUIIIIIIIIIIIIIIIIIIIIll 11111
Doc No: 10012752
Recorded: 06/07/2017 09:01:18 AM
Fee Amt: $26.00 Page 1 of 2
Duplin County North Carolina
Davis H. Brinson, Register of Deeds
BK 1860 PG 1002 -1003 (2)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
STATE OF NORTH CAROLINA
COUNTY OF DUPLIN
This Instrument has been filed for
Registration on the Date, Time and in the
Book and Page shown on the First Page
hereof, and is being returned for
your safekeeping.
Davis H. Brinson, Register of
NON -DISCHARGE WASTWATER SYSTEM WAIVER
1,
Address:
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
Pelmon Jart Hudson, Jr. , certify that I am a deeded owner of the property located at:
Parcel No.: 01-765
City: State: Zip Code: County: Duplin
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.
VI understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from 150 feet to 25 feet, thereby allowing the
application of wastewater effluent as near as 25 feet from my property line. For a period
of five (5) years.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
application of wastewater effluent as near as feet from my residence.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as _ feet from my property line.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as
Signature:
FORM: NDWSW 03-17
feet from my residence.
Date: I 2 '/-
Page 1 of 2

Book 1850
Page 1003
Applicant/Permittee: Murphy -Brown, LLC (W00013921)
Address: P.O. Box 856 Parcel No.:
City: Warsaw
State: NC Zip Code: 28398 County: ouplin
NORTH_CAROLINA, ') temp 6 on COUNTY
1, /!iekY/LA9 WIIII t 1 f c'Lk a Notary
Public for mpf)nn County, North Carolina,
do hereby ce tify that' R/07On C�Q f F hI i,d fit 11 personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the
SEAL
"OFFICIAL SEAL'
Notory Public, North caroms
county of Sampson
vielody J. Wi lif.rd
iAtn,issbn Expires
day of /770( , 026/'7
7)1tkdA., Q Li )�0,.t
Signature oJWotary Public
My commission expires
l V/aac20
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded
waiver shall be sent to the following address:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: NDWSW 03-17 Page 2 of 2

III IIIIIIIIIIIIIIIIIIIIIIIII IIhIII
Doc No: 10012753
Recorded: 06/07/2017 09:01:19 AM
Fee Amt: $26.00 Page 1 of 2
Duplin County North Carolina
Davis H. Brinson, Register of Deeds
BK 1850 PG 1004 - 1006 (2)
STATE OF NORTH CAROLINA
COUNTY OF DUPLIN
This Instrument has been tiled for
Registration on the Date, Time and in the
Book and Page shown on the First Page
hereol, and is being returned Inc
your safekeeping.
Davis H. Brinson, Register o
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTWATER SYSTEM WAIVER
I,
Address:
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
Murphy -Brown, LLC , certify that I am a deeded owner of the property located at:
Parcel No.: 01-2356
City: State: Zip Code: County: Duplin
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 a reduced setback from feet to feet, thereby allowing the
application of wastewater effluent as near as feet from my property line.
❑ I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
application of wastewater effluent as near as feet from my residence.
❑ I understand the setback requirements set forth in 1SA NCAC 02T. For the parcel identified
above, I consent to a reduced setback from feet to feet, thereby allowing the
construction of wastewater treatment and storage units as near as feet from my property line.
St I understand the setback requirements set forth in I5A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from 100 feet to 25 feet, thereby allowing the
construction of r stewa r treatment and storage units as near as 25 feet from any well.
�l 1�
Signature: , � Date: S1 i�
FORM: NDWSW 03-17
Page 1 of 2

Bock 1850
Page 1005
Applicant/Permittee: Murphy -Brown, LLC (W00013921)
Address: P.O. Box 856 Parcel No.:
City: Warsaw State: NC Zip Code: 28398 County: Duplin
NORTH CAROL NA, COUNTY
I, 1-1:o cl- Ck'c s- nl1,`rS , a Notary Public for (LUT I i r County, North Carolina,
do hereby certify that (t430 I V ,,LLJ i personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the I S day of Yi`Cij , -D P7,
Not G. CHgM''.,
gP 6
SE- pTAR(1' = i'LC.- C CmD,
=�G 008 L\G V•a
''� COUN `. `%
,sIII
Signature of Notary Public
My commission expires
GL.4- l S, )-Di
Once notarized, this form shall be recorded at the Register of Deeds in the county or
counties in which the described properties are located. A copy of the recorded
waiver shall be sent to the following address:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
FORM: ND W S W 03-17 Page 2 of 2