WQ0022017_More Information Received_20230511

Initial Review
Reviewer
Nathaniel.Thornburg
Is this submittal an application? (Excluding additional information.) *
Yes No
If not an application what is the submittal type?* Annual Report
Residual Annual Report
Additional Information
Other
Permit Number (IR) * W00022017
Applicant/Permittee Danny E. Blackburn, II and Patricia R. Blackburn
Email Notifications
Does this need review by the hydrogeologist? * Yes No
Regional Office
CO Reviewer
Admin Reviewer

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* Danny Blackburn
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*
9193695613
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:*
WQ0022017
Has Current Existing permit number
Applicant/Permittee Address*
9517 Walnut Grove Church Rd. Hurdle Mills, NC
27541
Facility Name*
9517 Walnut Grove Church Rd. SFR #1
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.)
Septic Info_000066.pdf 1.68MB
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 5/11/2023

IIIIIINIIIIINII11
Doc No' 30088040
Recorded: 05/1112023 11 55:58 AM
FeeFee $26.00 na / f
f 2
Excisese lax: 50.00
Orange County North Carolina
Mark Chilton. Register of Deeds
BK ti814 PG 2037 - 2038 (2)
: 7�,t,,
(TS1 r7 ► AJn r.4-t G"ve Ch u rc. ,k )eJ .
HiAr-d I,-- M i) I S 10 N C- a -75LH
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTWATER SYSTEM WAIVER
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
I5A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
f n.�uet C1 �f,�l�(Zt�rr1 , certify that I am a deeded owner of the property located at:
Address: 1351'7 hajn1,4,t %r os� t��� , _ Parcel No.: 99'7D8!q 95_$;P.
City: t- Ardlam, R; (!s State: L.lip Codc: a75 County:
Furthermore, I certify that I am authorized to make decisions regarding this property, and that 1 do hereby
agree that the setback distances cited below he granted to the Applicant/Permittee listed on the following
page -
al I understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reduced setback from 160 feet to feet, thereby allowing the
application of wastewater effluent as near as (f IG feet from my property line.
0 1 understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, 1 consent to a reduced setback from 400 feet to a�(o feet, thereby allowing the
application of wastewater effluent as near as A00 feet from my residence.
❑ 1 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.
❑ 1 understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, I consent to a reducq setback fr feet to feet, thereby allowing the
constructio7ofastea te r tment d or nits as near as feet from my residence.
Signature: te: 5-w' -D- 3
FORM: NI)WSW 03-17 Page I ol'3

BK 6814 PG 2038 DOC# 30088040
Applicant/Permittee
Address:9601-1� }nWnAAA 6milf. eitkrrh Ra Parcel No.: qq'? ()95()I4i
City: f-�,rd �e M i (t,S State: _&I&_ Zip Code: a 71jL4 t County: 13 rr
NORTH CAROLINA, )V (X_ COUNTY
1, N�0 b4U A. %1 b(k-jj , a Notary Public for !�1 I 1 County, North Carolina,
do hereby certify that WIAN 81 e1C(ol nl -t ulf"sonally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the AD— day of
QS
v NOTARY NZ
PUBLIC
spy si n E Signature of Lary Public
O` Gl �ygA,- My commission expires
.sue
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

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PASTURE / WOODLAND
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DANNY B. BLACKBURN t FAMCIA R. BtACKBURN
LOCATW OF fMPROVj%$Wr5 / pROP09CD 3rRAY ARUM
* AR.Z M9 TOVIM$tlIF ORANGe COVNTt+ NC9FTt1 CARf%Mu
MARCH 10. 2017
/. N 64°23125R W
N 64!232.5' w
FIGURE 2
9517 WALNUT GROVE CHURCH ROAD
NORTHERN PORTION OF 37,2-ACRE PARCEL
SINGLE-FAMILY RESIDENCE SPRAY SYSTEM
ORANGE COUNTY
WQ0022017
SITE DETAIL MAP

IF. NO
AC -AIR CONDITIONING UNIT
BOC-BACK OF CURB
BOX EL.ECTRIC AY EB
EOP-EDGE OF PAVEMENT
P-PATIO
\\\\\\\�``\N,,1111CA1(f//////////i
�`��C`•i•Q//�/
O
PO -PORCH
r
SCO-CLEANOUT
SEAL
SW -SIDEWALK
TP=TELEPHONE PEDESTAL
= L-4817 0-
� Z O
WM-WATER METER
, y
O IRON PIPE FOUND
C0) IRON PIPE SET
0 NAIL SET
/SIIMi0a\``•
NOTES:
1.AUL DISTANCES ARE HORIZONTAL GROUND DISTANCES IN
U.S. SURVEY FEET UNLESS OTHERWISE NOTED.
2.AREAS SHOWN HEREON WERE COMPUTED USING THE
COORDINATE METHOD.
3.UNES NOT SURVEYED ARE SHOWN AS DASHED LINES
FROM INFORMATION REFERENCED ON THE FACE OF THIS
PLAT.
4.PROPERTY MAY BE SUBJECT TO ANY/ALL EASEMENTS
AND RESTRICTIONS OF RECORD. THIS SURVEY IS A
CORRECT REPRESENTATION OF THE LAND PLATTED AND
OR DEEDED AND HAS BEEN PREPARED WITHOUT THE
BENEFIT OF A TITLE REPORT. A NORTH CAROLNA
LICENSED ATTORNEY -AT -LAW SHOULD BE CONSULTED
REGARDING CORRECT OWNERSHIP, WIDTH AND LOCATION
OF EASEMENTS, AND OTHER TITLE QUESTIONS
REVEALED BY TITLE EXAMINATION.
S.ALL VISIBLE ENCROACHMENTS ARE SHOWN HEREON.
B. THIS PROPERTY IS NOT LOCATED IN A FEMA
100 YEAR FLOOD HAZARD AREA PER MAP
37410996000L DATED 11/17/2017.
1 11. 4 78' w Z11.13
C2 39.08 803.56 IN 7324 56 W 139.08
L1
N 78'1807 E
70.35
L2
N 71.2 33 E
68.12
N 7 15 7
47. 7
L4
N 8(728 57 E
41.51
L7
S BS 17 33 E
29.71
La
S 76'0415
.75
ZONING AR
SETBACKS
N/F
DANNY & PATRICIA
BLACKBURN
DB 2301 PG 367
997
PIN 9970-84-9582
L6 LOLL
THIS EXHIBIT MAP IS OF AN EXISTING PARCEL OR
PARCELS OF LAND AND DOES NOT CREATE A NEW
STREET OR CHANGE AN EXISTING STREET.
NICHOLAS M. FRENCH. PILS L-4817 DATE
THIS MAP IS ONLY INTENDED FOR THE PARTIES
AND PURPOSES SHOWN. THIS MAP IS NOT FOR
RECORDATION. NO TITLE REPORT PROVIDED.
THIS MAP MAY NOT BE A CERTIFIED SURVEY AND
HAS NOT BEEN REVIEWED BY A LOCAL
GOVERNMENT AGENCY FOR COMPLIANCE WITH ANY
APPLICABLE LAND DEVELOPMENT REGULATIONS
AND HAS NOT BEEN RENEWED FOR COMPUANCE
WTH RECORDING REQUIREMENTS FOR PLATS.
THIS PROPERTY IS LOCATED WITHIN THE
FLAT RIVER PROTECTED OVERLAY DISTRICT
N
s
p ly�pp
/
/ 5.44AC/-GROSS
-0.58 AC.H- RW
DISTURBED AREA
4.86 AC. -/- NET
13.925 SF \��" Ns,
363.3
\ \$, H
72T552,W
180.2,
. — ` 01 0.1g
r'1 — — -
FRONT 40'
SIDE 20'
REAR 20'
GRAPHIC SCALE
100 0 50
L 1 inch = 100 ft.
FLAGS
LOCATED
IN FIELD
M
Cl
S 86'15'59" E 146-82'
B R E E Z E R 0 A D
60' PUBLIC R/W
REV1510N: ADJUST DRIVE; ADD DISTURBED AREA 2/13/23
REVISION: ADJUST DRIVE; ADD DISTURBED AREA 11/18/22
154.g--zzq
zU
U
1 �
NO m
2
J
S 86'15'59" E 232.78'
3
IMPERVIOUS AREA
HOUSE 3,071 SQ.FT.
DRIVE/WALK 3.535 SQ.FT.
PATIO 0 SQ.FT.
TOTAL 6,606 SQ.FT.
% OF LOT 3.1%
PROJECT: AMP BLACKBL7RN FOR S�
'^m1 DRAWN BY: N­AMERICAIS HOME PLACE E C L
•+ SURVEYED BY: N,A 9517 WALNUT GROVE CHURCH ROAD G L ❑ E3 A L,
.,.
LOT 2 U.S. VETERAN -OWNED
SCALE: 1,=1 Op' 'MINOR SUBDIVISION PLAT FOR DANNY BLACKBU RNA 19 N MCKINLEYLEY ST ST
NCEDAR GROVE TWP., ORANGE CO., NC COATS, NC 27521
FIELD WORK: DWG DATE: 91 O.B97.3257eriL, ca�oenLlHc.cI
N/A 11/17/22 BK 125 PG 65, PIN# 9970-95-0146 91 ❑.897.2329 l�Ax7 co#c n175�