WQ0010358_More Information (Received)_20240829

BK 2427 PG 0114
FILED
CHATHAM COUNTY NC
LUNDAY A. RIGGSBEE
REGISTER OF DEEDS
FILED Aug 13, 2024
AT 11:26:32 am
BOOK 02427
START PAGE
0114
END PAGE
0115
INSTRUMENT #
06948
EXCISE TAX
(None)
State of North Carolina
Department.of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTWATER SYSTEM WAIVER
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
I, Norton P. Scott , certify that I am a deeded owner of the property located at:
Address: �2� �,�o C U "� d ��� Parcel No.: 91869
City: Bear Creek State: NC Zip Code: 27207 County: Chatham
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 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 75 feet, thereby allowing the
application of wastewater effluent as near as 75 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
construe ' of wastewater treatm t and storage units as near as feet from my residence.
Signature: Date: 2�
FORM: W 03-17 Page 1 of 2
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2/13 / �a�

BK 2427 PG 0115
Applicant/Permittee: L a*-4 Coxo`e,
Address: O� 11 �1Y'lS' h Chl)MV" Parcel No.:
City:7r—) Ed _ .` 3�Q� State:/ke— Zip Codet;Z7A07 County: C nATH�iq
NORTH CAROLINA, - COUNTY
gawk a Notary Public for ,Cps County, North Carolina,
do herebycertifythat ✓� 1 �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 •A ,
SV
NOTAR y fir' = Signature of Notary Public
PUBLIC My commission expires
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