WQ0033325_Renewal Application_20230223

Initial Review
Reviewer
Nathaniel.Thornburg
Is this submittal an application? (Excluding additional information.) *
Yes No
Permit Number (IR) *
WQ0033325
Applicant/Permittee
Bladen County
Applicant/Permittee Address
PO Box 2350, Elizabethtown,
NC 28337
Is the owner in BIMS? Yes No
Is the facility in BIMS? Yes No
Owner Type
County
Facility Name
Tobermory Well
County
Bladen
Fee Category Minor
Fee Amount $0
Is this a complete application?*
Complete App Date
Yes No
02/23/2023
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer
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* Alan Edge
Email Address*
[e-mail]
Project Information
.........................
Application/Document Type*
New (Fee Required)
Modification - Major (Fee Required)
Renewal with Major Modification (Fee
Required)
Annual Report
Additional Information
Other
Phone Number*
9108626996
Modification - Minor
Renewal
GW-59, NDMR, NDMLR, NDAR-1,
N DAR-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://edoes.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:*
Wastewater Irrigation
High -Rate Infiltration
Other Wastewater
Reclaimed Water
Closed -Loop Recycle
Residuals
Single -Family Residence Wastewater
Other
Irrigation
Permit Number:*
WQ0033325
Has Current Existing permit number
Applicant/Permittee*
Bladen County
Applicant/Permittee Address*
PO Box 2350, Elizabethtown, NC 28337
Facility Name*
Tobermory Well
Please provide comments/notes on your current submittal below.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
Wastewaterirrigationchickenfootrenewal2023.pdf 1.35MB
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.
* 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
6ka�C�ye
2/23/2023

State of North Carolina
`'Division of Water Resources
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .0500 — WASTEWATER IRRIGATION SYSTEM — RENEWAL
FORM: WWIS-R 02-21
Pursuant to 15A NCAC 02T .0107(bl, 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 htt s:Hedoes.de .ne. ov/Forms/NonDischar e-
Branch-Submittal-Form-Vert, or emailed to Non -Discharge. Repo rtsknedenr.gov if less than 20 megabytes (MB).
` SECTIQl�I tPIsTC ANT 13y'01R1VlATTQi1T
L -
1. Applicant:
Q t 5 R l
_jAelir
2. Permit No.: WQ00 33 3 ,� g
3. Signature authority: ./
Title:
Phone number: 0P) S� ;�- 6,70 lect
Email:
`=
4. Mailing address:. P- o. ArX g6-r
City: &^11 �j�'7'�+ 4vzjA)
State: [ Zip:
5. Contact person: A l A r J U9 C:
Email: ea e -d j e° l e^ G O• d f
Primary phone number: (Q 1 o) 87(; yj b $elect
Secondary phone number: (4 a a) 8b : bQgifelect
1. Physical address: 31 -2,R CAi GJ4"
City: 5+. 17A ct [ S
2. Treatment facility coordinates to the sixth decimal degree:
Latitude:-TY,01a0$8° Longitude.-7,f88S+f2. 6°
County: 13L A 41e-tj Parcel No.: o o L69 10 1?
State: NC Zip: 2j 3 9f
Method: Select
s _ SECTIQIII FLDWI�IFORMAfiON
. _,_
� , _ ,.w x..,..� . �. ���s ... ,_ � ter., ... •-� _, � �.� _ �� -�� r. ,,,� ,� ., � H, ��, . � ' . �. � � �,�
1.
Permitted flow: 1143 GPD (The maxinnrm allowable flow based on what has been permitted)
2.
As -built flow: J( Y3 GPD (The maximum allowable flow based on what has been constructed)
3.
Average fie w- t GPD (The average of all reported flows on the previous calendar year's NDMRs)
4.
Hydraulic capacity: % (Divide the average flow in Item 3 by the As -built flow in Item 2)
5.
Wastewater composition: Domestic: t Wlo Industrial: % StorEnwater: %
_ SECTION IV :BIL�X�tG INF
1. Billing address: Q....�p,Y a JSp
City: [^11'ot bG.�!n ct1� State: AC zip:.ZS33
2. Verify the Applicant does not have any overdue annual fees:
littps-//deq.ne.gov/about/divisions/water-resources/water-i-so rces- ermits/w -e a meats
Pursuant to 15A NCAC 02T .0120ic1, permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.

x
X
x
1. ORC:
Grade:
Certification No.:
Mailing address:
City:
State:
Zip: -
Phone number: ( ) - Select
Email:
2. Back -Up ORC:
Grade:
Certification No.:
Mailing address:
City:
State:
Zip: -
Phone number: ( ) - Select
Email:
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
Select Select _
Select
Select
°
_ °
Select
Select
Select
Select
°
_ °
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
yOrECTtQN�riiiO,I3 ORING yUELY.S
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
Select
Select
Select
°
Select
Select
Select
°
Select
Select
Select
01
°
Select
Select
Select
°
°
Select
Select
Select
°
°
Select
Select
Select
0
°
Select
Select
Select
°
- °
Select
Select
Select
°
°
Select
Select
Select
°
°
Select
Select
Select
°
- °
Select
Select
Select
°
- 0

x s SEL�TIO�IXRRTGATION 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
d hLd eij Vv5AV 7bYB Q hi i' o.7 z U e a .8�1" ° r s
0 0
° °
° 0
° 0
0 0
0
° °
0 °
0 °
0 0
0 0
0 °
0 °
° o
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
MI N.
Total Acreage: . %
r

x
X
X
Was the facility originally permitted or had a major modification issued after September 1, 2006?
✓❑r Yes — Pursuant to 1_5A_ NCAC 02T .0105(d), submit a site map pursuant to the requirements in 15A NCAC 02T .0504(d).
These requirements are:
❑ 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 inrigation sites.
❑ All habitable residences or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
❑ No — Skip Attachment A.
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 dele at�on...letter pursuant to 15A NCAC 02T .0106 c authorizing the signature authority to sign.
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 .OI 14(fl.
❑ No — Skip Attachment C.
Is the Applicant a Privately -Owned Public Utility?
❑ Yes — Pursuant to 15A NCAC 02T .0115 a 1 I submit the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility fianchise.
❑ No -- Skip Attachment D.
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-Iaws.
❑ Yes (Developer of Lots to be Sold) — Pursuant to 15A NCAC 02T .01 15 &2), submit an executed Operational Agreement
(FORM: DEV). Pursuant to 15A NCAC 02T .01 15(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.

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33031VhOIM32[ Nb131 � U'
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HJ,ALN iUUNTY WATER SYSTEMNare, s7 Au s OOM1011; 034'BACYAS$W[date:194f2[tLB AI 'UNP I ineb equals S333 feet 3LADENCCtNIyYST+
C
rOgyig6(P) eat, Mapi,,ah, tnc, SITE LOCATION ;MAP

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05
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ATTACHMElT+ .DEMONSTRATION E3F I UTUiEASTl[1VF'ATERRE! T11�ElyT CAPAG3TIT
Is the applicant a municipality, county, sanitary district, or public utility?
❑ Yes -- Proceed to the next question.
❑ 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 .01 18l , 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.
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 Pennittee.
4 4TTACHInLrIT %I ATILTAN
Are the Permittee's affiliations of record correct? Check affiliations.
❑ Yes -- Skip Attachment H.
❑ No Provide the corrected affiliations and their contact information.
ATTA CHMEIT I co1LIAItHEpiE
Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
❑ Yes — Submit documentation that the compliance schedules have been met.
❑ No — Skip Attachment I.
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.

Does the wastewater composition in Section III, Item 5 include any industrial wastewater?
❑ Yes — Proceed to the next question.
❑ No -- Ship 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 021.0504(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.
Does the existing permit include setback waivers?
[ryes — 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.
THE
.. . �., •... ', ,� „ � A�PL�CAI�T'S GEl!2TICFICAT�O�1 s
I, attest that this applicati
( atur authority's name as noted in Section 1, 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. I 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 Applicant's Certification shall be signed pursuant to 15A NCAC 02T .0106(b). An alternate person may be delegated
as the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215.6A and § 143-215.6B,
any person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a
Class 2 misdemeanor, which may include a fine not to exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date: -Z
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email: Lasert'iche Upload:
Non-Discharge.Renorts?ncdenr.Qov https://ed_oes.deq.itc.i!oy/Forms/NoiiDischarge-Branch-
Submittal-Form-Ver2

FILED
BLADEN COUNTY NC
BEVERLY T. PARKS
REGISTER OF DEEDS
FILED Feb 01, 2017
AT 09:17:47 am
BOOK 00756
START PAGE
0963
END PAGE
0964
INSTRUMENT #
00319
EXCISE TAX
(None) i!
State of North Carolina
Department of Environmental Quality
Division of Water Resources'
NON -DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORMAMYBEPHOTOCOPIED FOR USE ASAAr 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:/%porial.ncdenr.org/web/wg/a s/lau/apj2licatfons.
INSTRUCTIONS TO THE APPLICANT:
✓ Do not' ubmit 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 0.2T 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: . Biaden County Water District
Complete mailing address of applicant: PO BOx 2350
City: Elizabethtown
Telephone number: 91 0 8 6 2— 6 9 9 6
State: NC
Zip:
28337
Facsimile number: 91 0 8 2-7
Hereinafter referred to as the Permittee, to (check all that apply):
ONon-Discharge disposal of wastewater effluent within ID 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
r
Page I of 2

BK:00756 PG:0964
.ie waived setbacks apply as shown on the attached map and located at the following:
Location address of property
City: St Pauls,
8129 Chackenf'oot Road
State: NC
Zip:
28384
L�X 1 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
a ro riate Register of Deeds and rovide the Permittee and Division of Water Resources with documentation of
such.
Property owner(s) name(s): Bladen County Water
Signature:
Signature:
CountManager �7�
ate:
Date:
NORTH CAROLINA, . J� 1 a. A e COUNTY
I, Mete ti w C . C-J- 3 ��c J , a Notary Public for County, North Carolina,
do hereby certify that ! V . AI%Ai4 ,i personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the 2-1 41' day of o r
s
,SEALS O TA �4N p
rfrrr�lt+++`�
Q—
Signature ofNotaq Public
My commission expires 6tl W-; S— old _
FORM: NDWSW 10-16 Page 2 of

0L/09/2017 23:11 9108626725 BLADEN PURCHASING PAGE 01
FILED
BLADEN COUNTY NC
BEVERLY T. PARKS
REGISTER OF DEEDS
FILED ,Jan 18, 2017
AT 09;02,,49 am
BOOK 00756
START PAGE 0355
END PAGE 0356
INSTRUMENT # 00162
State of North Carolina EXCISE TAX (None)
Department of Environmental Quality
Division of Water Resources
NON-DISCHARG)E WASTEWATER SYSTE. M WAIVER
(THIS r'01?MMAY,6E P110TO COPMEP roR risnAsAiv t:►lounvAr)
The Division of Wutcr Resources will not consider this form complete unless all instructions are followed. Vnilure
to follow instructions or to submit all required items will lead to ad(yxtlonal processing and review time,
For more information or for an eleetronic version of tjj& farm, visit Our web site of;
harta1. rrcdear ar /w�Ah„rLo i J�!an Licatiar,
INSTRUCTIONS TO M AP1P'.I,.TCANT:
✓ ❑o not submit this form for review without a oorrespondhig 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 I)e waived
through execution of this form.
✓ A copy of the conaplcted and appropriately executed form must be, provided to the property owner.
AGREEMENT TO WAIVE SETSACX8 AS I�EQUIIUr.0 6X
15A NCAC 02T .0506(a), ,0506(b), .0606(n), .0706(a) and .1006(a)
The undersigned property owners) hereby permits:
Applicant's name. Bladen County Water District
Complete mailing address of applicant: PO Box 2350
CRY: El izab-ethState: NC , Zip. 28337
Telephone number; (p i 0 ) 85.2-6 9 96 .
Facsimile number: (9l 0 ) 862-7869
.i 9roinafter referred to as the Permittee, to (check all that apply).
[O"'N'on-Discharge disposal of wastewater et'tluent within , Meet of the property line,
© Non -Discharge disposal of wastewater effluent within feet of the identified residence,
El Construct treatment and storage units within feet of the property line,
] Construct treatment atwd storage units within „ feet of the identirled residence.
FORM: NDWSW IN16 page 1 af2

23:07 9108626725 BLADEN PURCHASING PAGE 01
BK: 00756 PG- 0356
rho waivcd setbacks apply as sbown on tine attached snap and lovated at the following:
Location address of property: 8129 . Chickenfooh Rd
City_ St ,Eau s,, State: Mr_ zip: 28384
C certify that t am a, needed 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
constrict wastewater treatment units as specified herein. i furtllet' cc that I wi11 record this waiver fornn With the
suci
Property owner s) na a(:
Sig��atu�'e•
Signature:
CAROI,IiA,
J,
do hereby certify that _ 012 'L
Date:
Date: p�
—COUNTY
a NotaryP bile for L� County. North Carolina,
personally appeared before me this day and
acknowledged the due execution of the foregoing isistrumcAt.
Wj'tliess sty hand and official seal this the day of Ul&i AS
05 _I i
Signature of Notary .public
Q T,4
�.'tfIIC,
ropm., NDWSW 10.16
My rommbsivn drires
A,-P-s�21
Page 2 of 2

FILED
BLADEN COUNTY NC
BEVERLY T. PARKS
REGISTER OF DEEDS
FILED Jan 18, 2017
AT 09'.08: 44 am
BOOK 00756
START PAGE
0359
END PAGE
- 0360
INSTRUMENT #
00164
EXCISE TAX
(None)
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FOI?MMAYBE PHOTOCOPIED FOR USE AS gN 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 forth, visit our web site at:
hit :// ortal.ncdenr.or /web/w 1a s/laar/a lications.
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 WANE 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 Water Distri
Complete mailing address of applicant: P0 Box 23.50
City: El' htown State: NC Zip: 28337
Telephone number; 9{ 10) 8 6 2— 6 9 9 6
Facsimile number: (91 0) 8 6 2— 7 8 6 9
Hereinafter referred to as the Permittee, to (check all that apply):
VNon-Discharge disposal of wastewater effluent within S O feet of the property line,
❑ Non -Discharge disposal of wastewater effluent within feet of the identifiedresidence,
❑ 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

BK-00756 PG.0360
The waived setbacks apply as shown on the attached neap and located at the following:
Location address of property: 8129 Chickenfoot Road
City: St Pauls State: NC Zip: 28384
x 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 wa ver_for_m with the
appropriate Register. of Deeds and provide the Permittee and Division of Water Resources with documentation of
such.
Property owner(s) narne(s): Mary Beth Edge
Signature:
Signature:
NORTH CAROLINA, COUNTY
Data: i b -5 1 `?
Date:
I, 1 1 GL- G , ):mow r2-1e a Notary Public for GA- a e County, North Carolina,
do hereby certify that C,} -YA e � � .e personally appeared before me this day and
acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal this the 5 day of . �Jah 4 GY 7- j _ _ , 0 )
FLiL.I���
° O
�a " Signature ofNotafy Public
N
USLI , . My commission expires � � � � Q- o � I
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FORM: NDWSW 10-16 Page 2 of

ROY COOPER
Governor
MICHAEL S, REGAN
Secretary
S. DANIEL SMITH
Director
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
To Whom It May Concern:
NORTH CAROLINA
Environmental Quality
February 10, 2023
Subject: Permit NO. WQ00 3332.5
Signature Authority Designation
FACILITY
SELECT System
COUNTY County
As an appropriate signing official for 91,A p G'fJ CO- &)A- reXi S�FIt_r�c �� (city/town or
business name) as designated by 15A NCAC 2T .0106, I hereby delegate authority to sign and certify all
permit applications, reports or other permit related documents to the following staff for the following
permit types (sewer, spray, land application) and/or permit numbers:
Position
Person
Currently in
Position
Permit Type
or Permit
Number
'
00 333 ;zS
If you have any questions, please contact me at the following:
Permittee/Applicant name (please print):
Title: 6vc4A4t1 WAeidAgr aX
Complete mailing address: , D.
City: a� '4AFA -(W
Telephone number: { Ito )
State:
70
Facsimile number: (
Sincerely, ...........
signalw-e
Zip: .Y3 37
lv*4 �
"EQ7 North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
r:namH r�wra rNn �