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HomeMy WebLinkAboutWQ0010583_Additional Information Response_202201251
Plummer,Lauren
From:Brent Collins <brent.collins@emaresourcesinc.com>
Sent:Tuesday, January 25, 2022 12:25 PM
To:Plummer,Lauren; Lambert, Johnny
Cc:Thornburg, Nathaniel; Snider, Lon; Graznak, Jenny; Caudle, Caitlin
Subject:[External] RE: WQ0010583 - Davie County Class B Residuals Program - Additional
Information Request
Attachments:DV008-(5-9)(2).pdf; DV008-(2).pdf; Taylor Waiver.pdf; Whitaker Waiver.pdf; Residuals
Information Sheet.pdf; LASC.pdf; Pages from RLAP-06-16.pdf; Spillman LOA.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good morning. I have included the corrections/responses to your points below. Please let me know if you have any
questions.
B.
1. Field DV008-04 has been redrawn to remove the part that was redrawn inadvertently. Field DV012-
03 is now being deleted.
G.
1. Mr. Dooley has been dealing with dementia and we have been speaking with his wife and children
about remaining in the program. They have decided not to renew and we have changed the LASC to
reflect these changes.
2. We have not land applied on any of the sites referenced so there was no cumulative data to include.
H.
1. The map for DV008-04 has been redrawn to remove the part that was added inadvertently. DV012-
03 is being deleted.
2. The map has been updated with verbiage noting a redefined compliance boundary. The s econd page
of the LOA has had the redefined compliance boundary requested checked.
3. The initial map that was submitted for the permit modification that added DV008-09 has been
included at 1:440 scale with the drain added to the “wet area.”
4. The waivers have been attached.
I.
1. The 8/10/2021 sample is the most recent analysis of the material being generated. The calculations
have been corrected to reflect this analysis. The dry tons that were increased were for the material
to be cleaned out due to storm damage to the basin. As it was stated when the modification was
requested, the dry tons can be modified once everything has been removed.
K.
1. The residuals information sheet has been corrected and included.
I will switch the modified pages in the permit renewal and send a completed renewal again through the website. I have
included the referenced pages that were modified. Please let me know if you have any other questions.
--
Brent Collins
2
Director of Technical Services
EMA Resources Inc.
From: Plummer,Lauren <lauren.plummer@ncdenr.gov>
Sent: Friday, January 21, 2022 3:30 PM
To: Lambert, Johnny <jlambert@daviecountync.gov>; brent.collins@emaresourcesinc.com
Cc: Thornburg, Nathaniel <nathaniel.thornburg@ncdenr.gov>; Snider, Lon <lon.snider@ncdenr.gov>; Graznak, Jenny
<jenny.graznak@ncdenr.gov>; Caudle, Caitlin <caitlin.caudle@ncdenr.gov>
Subject: WQ0010583 - Davie County Class B Residuals Program - Additional Information Request
Mr. Lambert,
Division of Water Resources’ Central and Regional Office staff have reviewed the application package for the above
referenced project. Additional information is required before the review may be completed. Please address the items
identified in the attachment no later than the close of business on February 21, 2022.
Please be aware that failure to provide the requested information within the 30-day time frame may result in your
application being returned as incomplete. If you have any questions or concerns regarding this request, please do not
hesitate to contact me via email.
Sincerely,
Lauren Raup-Plummer, PE
Environmental Engineer III
Non-Discharge Branch
Department of Environmental Quality
919-707-3660 office
Lauren.Plummer@ncdenr.gov
512 N. Salisbury St
1617 Mail Service Center
Raleigh, NC 27699-1617
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Effective September 20, 2021, the Non-Discharge Branch is at half-staff. As a result, our response and review times
may be slower than normal. Thank you in advance for your patience.
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5
Source: Esri, Maxar, GeoEye, Earthstar Geographics, CNES/Airbus DS,USDA, USGS, AeroGRID, IGN, and the GIS User Community
Davie CountyLand Application Program
NC-DV-008Roger Spillman
2
WQ0010583
BC
SCALE:
PROJECT NO:
DATE:
DRAWN BY:
FIGURE NO.
01-25-22
1 " = 440 'C:\Users\letsg\Documents\ArcGIS\GIS Data\Davie County\Maps\DV008-(2).mxd±
Drain
!!!!!!Stream
Buffer
Wet Are a
Field Boundary
Property BoundaryFieldTotal Acres Applicable Acres930.68 23.67
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L a k e w o o d V i l la g e R d
6
Source: Esri, Maxar, GeoEye, Earthstar Geographics, CNES/Airbus DS, USDA, USGS, AeroGRID,IGN, and the GIS User Community
Davie CountyLand Application ProgramNC-DV-008Roger Spillman 2WQ0010583BC
SCALE:
PROJECT NO:
DATE:
DRAWN BY:
FIGURE NO.C:\Users\letsg\Documents\ArcGIS\GIS Data\Davie County\Maps\DV008-(5-9)(2).mxd±
1 " = 660 '01-25-22
Fi e ld Total Acres Appl i cable Acres519.77 17.66621.94 19.08757.83 42.9827.2 17.09930.68 23.67
Legend
!Well
#Structure
"On Site Dwelling
"Off Site Dwelling
Drain
!!!!Stream
Pond
Buffer
Wet Area
Field Boundary
Property Boundary
Rock Outcrop
Field NC -DV008-07 and NC -DV008-08 wi l l have an al te rnative compli ance boundary of 50' from each water suppl y wel l that i s l ocated wi thi n 250' of the resi dual l and appli cation area, that i s not al so wi thi n 50' of the propre ty boundary.
LAND APPLICATION SITE CERTIFICATION FORM: LASC 06-16 Page 1 Applicant's name: Davie County Land application sites currently certified: 363.14 net acres and Total to be certified: 179.7 net acres. I. LAND APPLICATION SITE INFORMATION (See Instruction B): Status Codea Site/Field ID Landowner(s) Lessee(s) or Operator(s) Net Acres County Crop(s) Predominant Soil Series Nameb Mapping Unit or Rep. Slopec M NC-DV-008-04 Roger Spillman 18.08 Davie Fescue Cecil CeB2 M NC-DV-008-05 Roger Spillman 17.66 Davie Fescue/Small Grain Mecklenburg MrC2 M NC-DV-008-06 Roger Spillman 19.08 Davie Fescue/Small Grain Mecklenburg MrB2 M NC-DV-008-07 Roger Spillman 42.9 Davie Fescue Mecklenburg MrB2 M NC-DV-008-08 Roger Spillman 17.09 Davie Fescue Mecklenburg MrB2 R NC-DV-008-09 Roger Spillman 23.67 Davie Fescue Mecklenburg MrB2 R NC-DV-009-01 Thomas Whitaker 6.48 Davie Fescue Tomlin ToB2 R NC-DV-009-02 Thomas Whitaker 15.75 Davie Fescue Tomlin ToB2 D NC-DV-012-01 Herbert Dooley 15.43 Davie Fescue Clifford CfB2 D NC-DV-012-02 Herbert Dooley 9.48 Davie Fescue Fairview FeC2 D NC-DV-012-03 Herbert Dooley 8.46 Davie Fescue Fairview FeC2 D NC-DV-012-04 Herbert Dooley 13.44 Davie Fescue Fairview FeC2 D NC-DV-012-05 Herbert Dooley 16.19 Davie Fescue Cordorus CoA D NC-DV-125-05 Edward Leagans 4.80 Davie Fescue Mecklenburg MrB2 D NC-DV-125-06 Edward Leagans 16.40 Davie Fescue Mecklenburg MrB2 D NC-DV-125-07 Edward Leagans 6.80 Davie Fescue Mecklenburg MrB2 D NC-DV-125-08 Edward Leagans 9.50 Davie Fescue Mecklenburg MrB2 D NC-DV-125-23 Edward Leagans 4.75 Davie Fescue Mecklenburg MrB2 D NC-DV-125-40 Edward Leagans 4.60 Davie Fescue Mecklenburg MrB2 D NC-DV-125-41 Edward Leagans 21.70 Davie Fescue Mecklenburg MrB2 D NC-DV-192-01 Cletus Miller 12.00 Davie Fescue Cecil CeB2
LAND APPLICATION SITE CERTIFICATION FORM: LASC 06-16 Page 2 D NC-DV-192-03 Cletus Miller 41.50 Davie Fescue Cecil CeB2 R NC-RO-001-01 James Taylor 18.99 Rowan Fescue Appling ApB
FORM: RLAP 06-16 Page 2 of 5
III. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
1. Residuals Processing Facility’s physical address: 175 Hwy 801 South
City: Cooleemee State: NC Zip: 27014-
Coordinates: Latitude: 35○ 48′ 15″ Longitude: 80○ 33′ 40″
Datum: NAD83 Level of accuracy: nearest second
Method of measurement: GPS
2. County where residuals land application program is headquartered: Davie
3. List the Operator In Responsible Charge (ORC) and all Back-Up ORCs for the residuals land application program, their
certification numbers, and their affiliations in the following table:
Designation Name Affiliation Certification Number
ORC Roy Whitaker EMA Resources Inc. 13283
Back-Up ORC Brent Collins EMA Resources Inc. 27651
Additional Back-Up
ORCs
(if applicable)
If an ORC and at least one Back-Up ORC are not currently designated for this residuals land application program, provide the
candidates’ names, affiliations, and an estimated time schedule for each candidate’s completion of the required training school
and certification test:
4. Complete the following tables regarding management of the residuals land application program:
a. Plant Available Nitrogen Summary: Determine the maximum plant available nitrogen (PAN) generated by all residuals
source-generating facilities as currently certified and proposed for certification with this application and list the results in the
following table:
Maximum amount of residuals to be certified: 2817 dry tons per year.
PAN Pounds of PAN per Dry Ton
(Weighted Average)
Pounds of PAN per Year
Surface Incorporation
or Injection
Surface Incorporation
or Injection
First-Year 16.06 22.27 45241 62735
Five-Year Maximum Adjusted 19.69 25.90 55467 72960
b. Land Application Site Use Summary: Summarize information regarding the land application sites as currently certified and
proposed for certification with this application:
Category Use Acres Comments
Crops Forest or Plantation 0
Row Crops 36.78
Hay/Pasture 142.92
Total: 179.7
Methods Surface 179.7
Incorporation or Injection 0
Total: 179.7
FORM: RLAP 06-16 Page 3 of 5
c. Residuals Land Application Summary: Determine the minimum acreage required to land apply the residuals as currently
certified and proposed for certification assuming the scenarios listed in the following table:
Assumed
Application Rate
(lbs PAN/ac-yr)
Acres Required Using
First-Year PAN Concentrations
Acres Required Using
Five-Year Maximum Adjusted PAN
Concentrations
Surface Incorporation or
Injection
Surface Incorporation or
Injection
50 905 1255 1109 1459
100 452 627 555 730
150 302 418 370 486
200 226 314 277 365
6. If applicable, provide a plan and a schedule to resolve any known issues that would prevent land application of the proposed
residuals due to the violation of North Carolina Administrative Code (e.g. not enough storage, not enough land, vector reduction
practices not in place, etc.):
7. Specify type of residuals program (See Instruction F): Non-dedicated Dedicated
If Dedicated, specify the following (check all that apply):
Residuals program contains any land application site(s) that receives residuals at rates or frequencies greater than agronomic
rates, explain;
Residuals program contains any land application site(s) that is used primarily for residuals disposal, and agricultural crop
production is of secondary importance, explain;
Residuals program contains any land application site(s) that receives residuals through fixed irrigation facilities or irrigation
facilities fed through a fixed supply system, explain;
IV. RESIDUALS SOURCE INFORMATION: (Required for all new, renewed, or modified residuals source)
Complete and submit the following Residuals Source Certification and all associated documentation.
Residuals Source
Certification
V. LAND APPLICATION SITE INFORMATION: (Required for all new, renewed, or modified land application site)
Complete and submit the following Land Applications Site Certification and all associated documentation.
Land Application Siite
Certification.doc
FORM: RLAP 06-16 Page 4 of 5
Note: Item VI. Applicable to Dedicated Program with fixed irrigation system only.
VI. DESIGN INFORMATION FOR FIXED IRRIGATION SYSTEM
1. The irrigation system is: Spray Drip
2. Disposal system is: existing proposed.
3. Minimum depth to mean seasonal high water table (SHWT) within irrigation sites(s) per Soil Scientist's Evaluation: feet
below ground surface. Rules 15A NCAC 02T .0505(p) requires at least one-foot vertical separation between SHWT and ground
surface.
4. Are there any artificial drainage or water movement structures within 200 feet of any irrigation area?
Yes or No If Yes, please explain if the soil scientist report addresses artificial structures and please indicate if
structures are to be maintained or modified:
5. Loading rates recommended by the Soil Scientist Evaluation:
Soil Series Fields within Soil Area
Recommended
Loading Rate
(in/hr)
Recommended
Loading Rate
(in/yr)
6. Design loading rates are equal or less than the loading rates recommended by Soil Scientist?
Yes or No If No, explain why 15A NCAC 02T .0505(n) is not met:
7. Non-dedicated System Design (fill in the appropriate information for either a spray or drip irrigation system):
Field / Zone Design Area
(ft2)
Number of
Nozzles
Maximum Application
Rate (gallons/hr)
Design Annual Loading
Rate (gallons/yr)
Total
Spray Irrigation Design Element Plan Sheet
Number
Specification
Page Number
Wetted diameter of nozzles ft
Wetted area of nozzles ft2
Nozzle capacity gpm
Nozzle manufacturer / model /
Elevation of highest nozzle ft
Residuals Information Sheet
Generator: Davie County
Facility: Cooleemee WWTP
Address: 175 Hwy 801 S
Cooleemee, NC 27028
Phone: 336‐751‐2635
Contact: Tim Smith
Land Application Contractor: EMA Resources Inc.
755 Yadkinville Rd
Mocksville, NC 27028
Phone: 336‐751‐1441
Contact: Brent Collins
Please Note: The application of these residuals is only allowed in accordance with subject permit.
(WQ0010583)
All applicable setbacks in accordance with 15A NCAC 02T .1108(b) will be adhered and is the
responsibility of the land application contractor.
Application rates shall be applied at agronomic rates for intended uses.
No residuals shall be applied to any site that is flooded, frozen, or snow covered.
Adequate procedures will be implemented to prevent surface runoff of residuals in any surface waters.
The attached residuals analysis report is a summary of major and micro‐nutrients available in the
residuals.
If you have any questions concerning this information, you may contact EMA Resources Inc, at the
number listed above.
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 – LAND OWNER AGREEMENT
FORM: LOA 06-16
FORM: LOA 06-16 Page 1 of 3
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section’s Non-Discharge Permitting Unit.
General – This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not submit
this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please do
not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: Davie County Land Application Program
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID Lease
(yes/no)
Land Use or
Cropping Patterns Intended Use of Crops Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
NC-DV-008-(04,07,08,09) No Fescue Pasture/Hay Feed/Food/Fiber
NC-DV-008-(05-06) No Row Crop Feed/Food/Fiber
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division’s permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Page 2 of 3
I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non-Discharge Permitting Unit, 1617 Mail
Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the land
application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of the
equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals land
application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final soil
pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of nutrients
(e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land application
events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land application
site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the posting of
signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land application
events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-month
period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land application
event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land application
event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
III. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105(h) allows the compliance
boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance boundary provided
the groundwater standards can be met at the newly-established compliance boundary. Please mark one of the following;
A re-defined compliance boundary is needed for field(s) ID: NC-DV008-07 & NC-DV008-08
(Please include the rationale for the requested re-location of the compliance boundary and attach a map showing the newly proposed compliance
boundary to the application package)
A re-defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
The land application field(s) ID: , is currently permitted under another
residuals land application program; Permit Number WQ: . The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: Aaq-v- Spr��MOn
Address: YO f30X /3a
City: Cooler.»eee State: IUC zip: 271DIg
Pho 336 - 91 6V60Ll E-mail address:
Signature: X ^no.... , Date:
NORTH CAROLINA, COUNTY
I, the undersigned Notary Public do hereby certify that 1 05,, 5P7 Il Mon
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
alsf
day of
Signature and seal: /'/ • .'C.Ae f
My commission expires: 3/30 /--&
M. awt cove
Lessee's/Operator's Certification: IMyCOIIM EVO=VAMh30,2M
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and1 do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official pelpe: �-O:rny !-ornb�r �' (J�'i��+i c5 1Ji rr•c '
Signature:
Date:
FORM: LOA 06-16 Page 3 of 3
State of North Carolina
Department of Environmental Quality
Division of Water Resources
111111111111111111111111111111111111111111111111111111111111111111111111 II\\\\\\ Doc ID: 014728660002 Type: CRP Recorded: 06/07/2021 at 02:14:32 PM Fee Amt: $26.00 Page 1 of 2 Rowan, NC J. E. Brindle ReQister of Deeds
BK 13 7 6 PG 717
NON-DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS B RESIDUALS
AGREEMENT TO WAIVE SETBACKS PURSUANT TO
15A NCAC 02T .1108(c)
I, AcloM lo't /or
Address: '-1 '7 (L,O NC ~O I J..I wy
City: \vooclle•i:-
, certify that I am a deeded owner of the property located at:
Parcel No.: BJ9 C,9 3
State: t,/C,.. Zip Code: 3. 7oS'( County: /Z.01,.J,o,._
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.
For the parcel identified above, I consent to a reduced setback from 50 feet to ___!2._ feet,
thereby allowing the application of Class B residuals as near as _!2__ feet from my property line.
~For the parcel identified above, I consent to a reduced setback from 1-/00 feet to Joo feet,
thereby allowing the application of Class B residuals as near as / oo feet from my residence.
**THIS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED**
Signature: =-X'--=-//L--'----'4---"n"-=--------------Date: )( q,/;?/2oz. f
FORM: NDRMPW-LAS 11-18 Page I of2
Applicant/Pennittee: ---=i)=--o-"'-· c:...---'-~-"_!'(....z_ __________________ _
Address: IZ 3 Sou~~ l>fa ,';I s./..
City: Aoc1£~,dlc..
Parcel No.: '6/ 9 09'{
State : fl)C Zip Code: 27DZ-'ir County: bi,,v,·e.
NORTH CAROLINA, _ _,i):;_4...;_.,,_i--"~---COUNTY
I, /t1. 8,-,11 -I-aw,., , a Notary Public for Llo..,: e County, North Carolina,
do hereby certify that At/Ml .1.:, kr personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the 7tlt day of_-':f.'-..,-"_<-___ _, 202 (.
SEAL It. Brant Collinl
Signature of Notary Public NOTARV PUBLIC
DIMl~NC
M-/CGmmlulmtExplras Mardi 30, 2028 My commission expires .3/Jo/,2.e,24,
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:
FORM: NDRMPW-LAS 11-18
Division of Water Resources
Non-Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Page 2 of2
FILED
DAVIE COUNTY NC
KELLY C. FUNDERBURK
REGISTER OF DEEDS
FILED Jun 01, 2021
AT 09:57 am
BOOK 01181
START PAGE
END PAGE
INSTRUMENT#
EXCISE TAX
State of North Carolina
Department of Environmental Quality
Division of Water Resources
0826
0827
03891
(None) ,
NON-DISCHARGE RESIDUALS MANAGEMENT PROGRAM WAIVER
FOR THE APPLICATION OF CLASS B RESIDUALS
AGREEMENT TO WAIVE SETBACKS J>URSUANT TO
15A NCAC 02T .1108(c)
I, el tth,'./-a ~.-r , certify that I am a deeded owner of the property located at:
Parcel No.: lf-4000DOO.¾,o2. Address: S3 D Cou N Tt'q' 7(
City: 6Y) /)C-IJ.Sc..J L LL€ State: NC-Zip Code<l-tO l-8
I
County: D 19-w !:::?""
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.
0' For the parcel identified above, I consent to a reduced setback from feet to feet,
thereby allowing the application of Class B residuals as near as _.t2_ feet from my property line.
ifF'or the parcel identified above, I consent to a reduced setback from ~I)~ feet to /Ill> feet,
thereby allowing the application of Class B residuals as near as tOV feet from my residence.
**THIS WAIVER SHALL BE TERMINATED UPON CHANGE OF OWNERSHIP OF ANY PARTIES INVOLVED**
Signature: x~j I A) \NJ~ Date: S-c:98--cJ..'
FORM:NDRMPW-LASil-1~, ~.()"c/<l-c::D VY\~ (_Q~J \N\S' --r' -a
r-t5'5 L\lldU( V\'\Y \ \ \ e_
VV\~\J( J(e )\)C &7~
Page I of2
Applicant/Permittee: Do" i C:,u/'1+'7
Address: I 2 S. '11a:"' S+.
City: fl'1 oc'ls:;-.i; \\ L
Parcel No.: H'-IDOOOoo.3loD 2
State: j\)C.-Zip Code: J. 7'iJ Z-'j' County: i:)O"I: e.
NORIB CAROLINA, i) Q"; COUNTY
I, fYI. ,'3r,wf-tj,tf,,M;, ,aNotaryPublicfor ... ;e.. County, North Carolina,
do hereby certify that_-..:...Fr"'"'r,;..:d;;.....;.f.J.;..h_;_+"l...;,.k._,-r ____ -.1Personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the of _ __._t'.!,_., ____ , .).o2..l
"EAL II. Brant Collinl
NOTARY PUBLIC
Davie Cculll NC Signature of Notary Public
My Commission Exp1ras Madi so, m My commission expires 3/SD/26::,
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:
FORM: NDRMPW-LAS 11-18
Division of Water Resources
Non-Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Page 2 of2