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HomeMy WebLinkAboutWQ0013921_Renewal Application_20211221Non -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* KWESTON@SMITHFIELD.COM 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 nathaniel.thornburg@ncdenr.gov. 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: (910) 293-3434 Office Email: jsargent@smithfield.com 4. Mailing address: P.O. Box 856 City: Warsaw State: NC Zip: 28398- 5. Contact person: Kevin Weston Email: kweston@smithfield.com Primary phone number: (910) 293-5363 Office Secondary phone number: (910) 290-3300 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: (910) 271-0917 Cell Grade: SI Certification No.: 27678 State: NC Zip: 28398- Email: debrown@smithfield.com 2. Back -Up ORC: Michael Leon Norris Mailing address: P.O. Box 856 City: Warsaw Phone number: (910) 293-5575 Office Grade: SI Certification No.: 23931 State: NC Zip: 28398- Email: mnorris@smithfield.com 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 N 025 a) ca U Update Permittee's Affiliations of Record as follows: smithfield.com E 0 0 c c 0 0 W Y UJ Y CO CO CO m m m (41 r rn N N x O x O a ra 1 LL 01 l.Ll 01 c C 0 L i4+ 0) = Contact Name Environmental Resource Specialist Kevin Weston Contact Person Permit Billin a! 0 L 0) v 0 0 v 0_ 0) 0 3 0 0) cc C a E c 0 N c I- w Contact Name Kevin Weston 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