WQ0033325_Permit Renewal_20170306

Environmental
Quality
RANDY GARNER — DIRECTOR
BLADEN COUNTY WATER DISTRICT
272 SMITH CIRCLE
ELIZABETHTOWN, NORTH CAROLINA 28337
Dear Mr. Garner:
March 6, 2017
ROY COOPER
• Governor
WILLIAM G. ROSS, JR.
Acting Secretary
Subject: Permit No. WQ0033325
Additional Information Request
Tobermory Well
Wastewater Irrigation System
Bladen County
Division of Water Resources' Central and Regional staff has reviewed the application package received
September 15, 2016. However, additional information is required before the review may be completed.
Please address the items on the attached page no later than the close of business on April 5, 2017.
Please be aware that you are responsible for meeting all requirements set forth in North Carolina rules and
regulations. Any oversights that occurred in the review of the subject application package are still the
Applicant's responsibility. In addition, any omissions made in responding to the appropriate items
outstanding in Sections A or B, or failure to provide the additional information on or before the above
requested date, may result in your application being returned as incomplete.
Please reference the subject application nurnber when providing the requested information. All revised
and/or additional documentation shall be signed, sealed and dated (where needed), with three copies
submitted to my attention at the address below.
If you have anyquestions regarding this request, please do not hesitate to contact me at [phone] or
[e-mail]. Thank you for your cooperation.
Sincerely,
David Goodrich, Hydrogeologist
Division of Water Resources
cc: Fayetteville Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Permit Application File WQ0033325
Notfling Compares:—
State of North Carolina i Environmental Quality
1611 Mail Service Center I Raleigh, North Carolina 27699-1611
919-707-9000

Mr. Randy Gamer
March 6, 2017
Page 2 of 2
A. Non -Discharge Wastewater System Waiver:
The setback waiver signed by Earl and Denise Goings on January 11, 2017 indicated that they were the
owners of the property located at 8129 Chickenfoot Road. That property is actually owned by the
Bladen County Water District. The correct address for the adjacent property owned by Earl and Denise
Goings has been entered into the waiver form we have filled out and attached herewith for your use.
Please have the attached waiver form completed, signed, sealed and recorded in the Bladen County
Register of Deeds, and copied to us.
B. Non -Discharge Wastewater System Waiver:
The setback waiver signed by Mary Beth Edge on January 5, 2017 indicated that she was the owner of
the property located at 8129 Chickenfoot Road. That property is actually owned by the Bladen County
Water District. The correct address for the adjacent property owned by Mary. Beth Edge has been
entered into the waiver form we have filled out and attached herewith for your use. The attached waiver
form has also had the setback adjusted from 150 feet to.5 feet.
. Please have the attached waiver form completed, signed, sealed and recorded in the Bladen County
Register of Deeds, and copied to us.

State of North Caroni a
Departtmen>t. of Environmental Quality
Division of Water Resources
NON- IISCHARGE WASTEWATE SYSTEM WAIVER
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructionsare followed. Failure
to follow instructions or to submit all required items _will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
http://portal.ncclenr.org/web/wq/aps/lau/applications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Non -Discharge Permitting Unit application form.
✓ Any, changes to this form will result in the application package being returned.
✓ Any other setbacks required by 15A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner.
• AGREEMENT TO WAIVE' SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) and .1006(a)
The undersigned property owner(s) hereby permits:
Applicant's name: Bladen County -
Complete mailing address of applicant: Post Office Box 2350
City: Elizabethtown State: NC
J Zip: 28337
Telephone number: ( 910 ) 862-6996 Facsimile number: ( 910J 862-7869
Hereinafter referred to as the Permittee, to (check all that apply):
• Non -Discharge disposal of wastewater effluent within 5 feet of the .property line,
❑ Non -Discharge disposal of wastewater effluent within feet of the identified residence,
❑ Construct treatment and storage units within feet of the property line,
❑ Construct treatment and storage units within feet of the identified residence.
FORM: NDWSW 10-16 Page 1 of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: 8287 Chickenfoot Road (Parcel No. 18090)
City: St. Pauls State: NC
Zip: 28384
® I certify that I am a deeded property owner of above -referenced property and am authorized to make decisions regarding
this property on behalf of other deeded property owners. Furthermore, I certify that I have read and understand this
Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or construct wastewater
treatment units as specified herein. I further agree that I will record this waiver form with the appropriate Register of
Deeds and provide the Permittee and Division of Water Resources with documentation of such.
Property owner(s) name(s): Earl & Denise Goings
Signature: Date:
Signature: Date:
NORTH CAROLINA, COUNTY
I, , a Notary Public for County, 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 L
SEAL
FORM: NDWSW 10-16
Signature of Notary Public
My commission expires
Page 2 of 2

State of North Carolina
Department of Environmental Quality
ivision of Water Resources
1
NON- ISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM MAY BE PHOTOCOPIED FOR USE AS AN ORIGINAL)
The Division of Water Resources will not consider this form complete unless all instructions are followed. Failure
to follow instructions or to submit all required items will lead to additional processing and review time.
For more information or for an electronic version of this form, visit our web site at:
http: //portal. ncdenr. org/web/wq/aps/lau/applications.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Non -Discharge Permitting Unit application form.
✓ Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by 15A NCAC Subchapter 02T other than those referenced below, cannot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the property owner,
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) and .1006(a)
The undersigned property owner(s) hereby permits:
Applicant's name: Bladen County
Complete mailing address of applicant: Post Office Box 2350
City: Elizabethtown State: NC
Telephone number: ( 910 ) 862-6996
Hereinafter referred to as the Permittee, to (check all that apply):
® Non -Discharge disposal of wastewater effluent within /
❑ Non -Discharge disposal of wastewater effluent within
❑ Construct treatment and storage units within
❑ Construct treatment and storage units within
FORM:,.NDWSW 10-16
Zip: 28337
Facsimile number: ( 910J 862-7869
5 feet of the property line,
feet of the identified residence,
feet of the property line,
feet of the identified residence.
Page 1 of 2

The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: Parcel No. 28326 off Chickenfoot Road
City: St. Pauls State: NC
Zip: 28384
I certify that I am a deeded property owner of above -referenced property and am authorized to make decisions regarding
this property on behalf of other deeded property owners. Furthermore, I certify that I have read and understand this
Agreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or construct wastewater
treatment units as specified herein. I furtheragree that I will record this waiver form with the appropriate Register of
Deeds and provide the Permittee and Division of Water Resources with documentation of such.
Property owners) name(s): Mary Beth Edge
Signature: Date:
Signature: Date:
NORTH CAROLINA, COUNTY
a Notary Public for County, 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
SEAL
Signature of Notary Public
My commission expires
FORM: NDWSW 10-16 Page 2 of 2

Barber, Jim
From: Goodrich, David
Sent: Monday, March 06, 2017 9:24 AM
To: Tina
Cc: Thornburg, Nathaniel; Barber, Jim
Subject: Additional Information Requested for Permits WQ0033325 & WQ0033942
Attachments: WQ0033942AddInfo170306.pdf; WQ0033325AddInfo170306.pdf
Hello Tina and Mr. Garner,
Please find the attached requests for additional information. These requests are also being sent to you by US mail.
Thank you.
Regards,
David Goodrich
David Goodrich
Hydrogeologist II
North Carolina Division of Water Resources
North Carolina Department of Environmental Quality
919 807 6352 office
david.goodrichCa ncdenr.gov
512 North Salisbury Street
1617 Mail Service Center
Raleigh, NC 27699-1617
'"Nothing Compares. —,
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
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