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Home My WebLink AboutWQ0016247_FP AttAB_20170731Water Resources ENVIRONMENTAL QUALITY July 31, 2017 WRLLIAM P. COTTER — REGIONAL VICE PRESIDENT SYNAGRO CENTRAL, LLC 284 BOGER ROAD MOCKSVILLE, NORTH CAROLINA 27028 Dear Mr. Cotter: ROY COOPER Governor MICHAEL S. REGAN Secretary S. JAY ZIMMERMAN Director Subject: Attachments A and B Certification Permit No. W00016247 Synagro Western Piedmont RLAP Alexander County In accordance with your permit modification request received May 4, 2017, and subsequent additional information received July 7, 2017, we are forwarding herewith modified Attachments A and B certified July 31, 2017, to Synagro Central, LLC for the subject residuals program. This certification is being issued to modify Attachments A and B by: 1. Addition of three new residuals sources with 325 tons/year, those sources being Granite Falls WWTP (200 tons/year), Granite Falls WTP (45 tons/year) and Columbus WWTP (80 tons/year). 2. Addition of five new fields in Polk County totaling 49.8 acres, those fields being NC-PO-06- 01 to 03, NC-PO-07-01 and NC-PO-07-02. 3. Addition of five new fields and one transferred field in Caldwell County totaling 72.3 acres, those fields being NC-CD-02-01 to -05 and NC-CD-15-01. This modified Attachments A and B shall be effective from the date of certification until February 28, 2018 (i.e., expiration date of the current permit), shall void Attachment A previously certified April 24, 2015, and Attachment B previously certified February 11, 2016, of Permit No. W00016247 issued on March 27, 2009, and shall be subject to the conditions and limitations as specified therein, as well as those specified in the above -referenced permit. Please replace the previously certified Attachments A and B of Permit No. W00016247 with these modified Attachments A and B. Please note that only the maps (Figures 9 to 13) for new land application sites are attached to this letter. It is the Permittee's responsibility to ensure that a complete permit is created by inserting these documents into the previously issued permit. --'7'Nothing Compares':--.._, State of North Carolina I Environmental Quality I Water Resources I Water Quality Permitting I Non -Discharge Permitting 1617 Mail Service Center I Raleigh, North Carolina 27699-1617 919-807-6332 Mr. William P. Cotter July 31, 2017 Page 2 of 2 If any parts, requirements, and/or limitations contained in this certification or modified Attachments A and B are unacceptable, you have the right to request an adjudicatory hearing upon written request within 30 days following receipt of the certification. This request shall be in the form of a written petition, conforming to Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative Hearings at 6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless such demands are made, this permit shall be final and binding. If you need any additional information concerning this matter, please contact Troy Doby at (919) 807-6336 or troy.doby@ncdenr.gov. Sincerely, S. Jay Zimmerman, P.G., Director Division of Water Resources cc: Alexander County Health Department (Electronic Copy) Mooresville Regional Office, Water Quality Regional Operations Section (Electronic Copy) Digital Permit Archive (Electronic Copy) Central Files ATTACHMENT A - Approved Residual Sources Synagro Central, LLC Certification Date: July 31, 2017 Permit Number: W00016247 Version: 3.3 Monitoring Monitoring Monitoring Permit Biological Maximum Frequency for Frequency for Frequency for Approved Owner Facility Name County Number Residuals Dry Tons Non -hazardous Metals and Pathogen & Mineralization Per Year' Characteristics 2 Nutrients s, s Vector Attraction Rate Reductions a s, 6 City of Statesville Third Creek W WTP Iredell NCO020591 Yes 972.9 Annually See Table Below' - See Table Below' 0.3 Town of Columbus ColumbusWWTP Polk NCO021369 Yes 80 Annually Annually Annually 0.3 Town of Granite Falls Granite Falls W WTP Caldwell NCO021890 Yes 200 Annually Annually Annually 0.3 City of Statesville Fourth Creek W WTP Iredell NCO031836 Yes 1,055.7 Annually See Table Below' See Table Below' 0.3 Stanly County Utilities West Stanly W WTP Stanly NCO043532 Yes 300 Annually Annually Annually 0.3 Town of Granite Falls Granite Falls W TP Caldwell NCO082546 No 45 Once per permit See Table Below None' - Total 2,653.E 1. Maximum Dry Tons per Year is the amount of residuals approved for land application from each permitted facility. 2. Analyses to demonstrate that residuals are non -hazardous (i.e., TCLP, ignitability, reactivity, and corrosivity) as stipulated under permit Condition 1V.2. 3. Testing of metals and nutrients as stipulated under permit Condition IV.3. 4. Analyses of pathogen and vector attraction reductions as stipulated under permit Condition WA. 5. Monitoring frequencies are based on the actual dry tons applied per year using the table below, unless specified above. Dry Tons Applied short tons Der ear(Established Monitoring Frequency in 40 CFR 503 and 15A NCAC 02T .1111 <i 19 l/Year =>319 - <1,650 l/ Quarter 4 times per ear =>1,650 - <16,500 1/60 Days 6 times per ear =>16,500 1/month 12 times peryear) 6. Class A water treatment plant residuals are exempt from meeting the pathogen & vector attraction reduction requirements in Condition IV A, provided they are not mixed with residuals that have been generated during the treatment of domestic wastewater, the treatment of animal processing wastewater, or the biological treatment of industrial wastewater. The Class A water treatment plant residuals must be treated and processed in a manner as to not meet the definition of `Biological Residuals" as defined in 15A NCAC 02T .1102(6). If no land application events occur during a required sampling period (e.g. no land application occur during an entire year when annual monitoring is required), then no sampling data is required during the period of inactivity. The annual report shall include an explanation for missing sampling data. Those required to submit the annual report to EPA may be required to make up the missed sampling, contact the EPA for additional information and clarification. W00016247 Version 3.3 Attachment A Page 1 of I y x r z x ATTACHMENT B - Approved Land Application Sites Synagro Central, LLC Certification Date: July 31, 2017 Permit Number: W00016247 Version: 3.3 Field/ Site Owner Lessee County Latitude Longitude et Acreage Dominant Soil Series Footnotes NC-AL-13-OIA Millsaps, Arlene Millsaps, Danny Alexander 35.880531 -81.127719 13.5 Pacolet NC-AL-13-OIB Millsaps, Arlene Millsaps, Danny Alexander 35.877117 -81.124533 16 CfB2 - Cecil NC-AL-13-02 Millsaps, Danny Ray Alexander 35.881317 -81.134081 16.6 CfB2 - Cecil NC-AL-14-01A Payne, J. Woodrow; Payne, Timothy L. Alexander 35.871872 -81.135206 19.2 Rion NC-AL-14-OIB Superior Jersey Farm Inc.; Payne, Timothy L. Alexander 35.869067 -81.132944 22.7 CfB2 - Cecil NC-AL-14-02 Superior Jersey Farm Inc.; Payne, Timothy L. Alexander 35.855778 -81.134353 43.4 Rion NC-AL-14-03 Superior Jersey Farm Inc.; Payne, Timothy L. Alexander 35.856253 -81.138697 23.2 CfB2 - Cecil NC-AL-14-04 Superior Jersey Farm Inc.; Payne, Timothy L. Alexander 35.854256 -81.141814 10.2 CfB2 - Cecil NC-AL-14-05 Superior Jersey Farm Inc.; Payne, Timothy L. Alexander 35.845575 -81.133697 27.9 CIB2 - Cecil Total forAlexander County 192.7 NC-CD-02-01 Hayes Family Farms, Inc. Caldwell 35.860344 -81.486053 13.3 FaB2 - Fairview 9 NC-CD-02-02 Hayes Family Farms, Inc. Caldwell 35.807961 -81.488889 11.2 FaB2—Fairview 9 NC-CD-02-03 Wilson, Troy E., Jr. Caldwell 35.804456 -81.491147 15.7 FaB2 — Fairview 9 NC-CD-02-04 Wilson, Jennie B., Living Trust Caldwell 35.804092 -81.493981 6.4 FaB2 — Fairview 10 NC-CD-02-05 Wilson, J. Dykes Caldwell 35.801452 -81.502878 11.1 WoB — Faiview- Woolwine 10 NC-CD-15-01 Prestwood, Louie; Prestwood, Nora Caldwell 35.853283 -81-515803 14.6 FaB2 —Fairview 11 Total for Caldwell County 72.3 NC-IR-20-01 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.797853 -80.775142 11.4 Appling NC-IR-20-02 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.798103 -80.771506 13.2 CfB2 - Cecil NC-IR-20-03 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.799286 -80.766903 11.6 j CfB2 - Cecil NC-IR-20-04A Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.795164 -80.759242 44.2 CfB2 - Cecil NC-IR-20-04B Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.792019 -80.760714 11.6 Cf32 - Cecil W00016247 Version 3.3 Attachment B . Page 1 of 4 ATTACHMENT B - Approved Land Application Sites Synagro Central, LLC Certification Date: July 31, 2017 Permit Number: WQ0016247 Version: 3.3 Field/ Site Owner Lessee County Latitude Longitude Net Acreage Dominant Soil Series Footnotes NC-IR-20-06 I Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.800886 -80.768147 18.6 Helena NC-IR-20-07 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.803008 -80.769211 13.9 Helena NC-IR-20-08 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.805719 -80.767864 11.2 Appling NC-IR-20-09 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.805042 -80.765931 12.2 CfB2 - Cecil NC-IR-20-11 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.809644 -80.762922 41.6 CfB2 - Cecil NC-IR-20-12 Sandra L. Phillips and Dennis G. Phillips Living Trust Iredell 35.808131 -80.766303 4 CfB2 - Cecil NC-IR-22-01 Robertson, William C. Porter, Eddie D. Iredell 35.845317 -80.745611 18.1 CfB2 - Cecil NC-IR-22-02 Robertson, William C. Porter, Eddie D. Iredell 35.849217 -80.742992 28.9 CfB2 - Cecil NC-IR-22-03 Robertson, William C. Porter, Eddie D. Iredell 35.848786 -80.747103 15.2 CfB2 - Cecil NC-IR-22-04 Robertson, William C. Porter, Eddie D. Iredell 35.847319 -80.748925 10.7 CtB2 - Cecil NC-IR-23-01 Page, Lorane Porter Irrevocable Dynasty Trust Porter, Eddie D. Iredell 35.839389 -80.731683 17.2 CfB2 - Cecil NC-IR-23-02 Page, Lorane Porter Irrevocable Dynasty Trust Porter, Eddie D. Iredell 35.835581 -80.726353 32.4 CfB2 - Cecil NC-IR-23-03 Page, Lorane Porter Irrevocable Dynasty Trust Porter, Eddie D. Iredell 35.843672 -80.727036 23 CfB2 - Cecil NC-IR-23-04 [Page, Loraine P.] J. W. Page Family Trust Porter, Eddie D. Iredell 35.840858 -80.723306 13.7 CE32 - Cecil NC-IR-23-05 [Page, Loraine P.] J. W. Page Family Trust Porter, Eddie D. Iredell 35.837833 -80.722264 16.1 CfB2 - Cecil NC-IR-25-01 [Gantt, Boyd] Gantt, James B.; Gantt, Joyce L. Warren, William R. Bob Iredell 35.800472 -80.786211 15.8 CE32 - Cecil NC-IR-29-01 Knox, Mary H. Living Trust Knox, Ben Iredell 35.732206 -80.752122 42.1 Mecklenburg Total for Iredell County 426.7 NC-PO-06-01 Holbert, Robert L.; Holbert, Linda Y. Polk 35.247275 -82.082739 8.1 1 CeB2 — Cecil 12 NC-PO-06-02 Holbert, Robert L.; Holbert, Linda Y. Polk 35.246589 -82.080647 16.2 CeB2 — Cecil 12 NC-PO-06-03 Edwards, Dale Y. Polk 35.244347 -82.079436 7.2 CeB2 — Cecil 12 NC-PO-07-01 Edwards, Danny K.; Edwards, Ethan L. Polk 35.222114 -82.084217 10.6 CeB2 - Cecil 13,17,18 NC-PO-07-02 Taylor, Roy Lee; Taylor, Emogene J. Polk 35.225783 -82.087303 7.7 PaC2 - Pacolet 13 W00016247 Version 3.3 Attachment B Page 2 of 4 ATTACHMENT B - Approved Land Application Sites Synagro Central, LLC Certification Date: July 31, 2017 Permit Number: W00016247 Version: 3.3 Total for Polk County 49.8 Field/ Site Owner Lessee County Latitude Longitude Net Acreage Dominant Soil Series Footnotes NC-ST-01-01 Misenheimer, Donald Eugene Stanly 35.291352 -80.345302 5.9 TbB - Tarrus 1 NC-ST-01-02 Misenheimer, Donald Eugene Stanly 35.291103 -80.347942 7.0 GeB - Georgeville 1 NC-ST-01-03 Misenheimer, Donald Eugene Stanly 35.290570 -80.350444 10.6 TcB2 - Tarrus 1 NC-ST-01-04 Misenheimer, Donald Eugene Stanly 35.288398 -80.350485 17.6 TcB2 - Tarrus 1 NC-ST-01-05 Misenheimer, Donald Eugene Stanly 35.326225 -80.349804 17.3 BaB - Badin 2 NC-ST-01-06 Misenheimer, Donald Eugene Stanly 35.328068 -80.353769 22.3 BaB - Badin 2 NC-ST-01-07 Misenheimer, Donald Eugene Stanly 35.327722 -80.337827 26.2 TbB - Tarrus 3 NC-ST-02-01 Little, Clifford Sylvestor Stanly 35.210528 -80.283348 16.0 BaB - Badin 4 NC-ST-02-02 Little, Sylvester Stanly 35.210398 -80.281238 5.3 BaB -Badin 4,14,15,16 NC-ST-03-01 Ridenhour, Robert Barrie Stanly 35.364397 -80.374313 19.1 BaB - Badin 5 NC-ST-03-02 Ridenhour, Robert Barrie Stanly 35.363526 -80.372367 3.3 BaB - Badin 5 NC-ST-03-03 Ridenhour, Robert Barrie Stanly 35.368843 -80.374142 24.6 BaB - Badin 5 NC-ST-03-04 Ridenhour, Robert Barrie; Ridenhour, Billy Joe Stanly 35.378182 -80.364293 8.4 GoC - Goldston 6 NC-ST-03-05 Ridenhour, Robert Barrie; Ridenhour, Billy Joe Stanly 35.375559 -80.361261 12.4 GoC - Goldston 6 NC-ST-03-06 Ridenhour, Robert Barrie Stanly 35.372552 -80.362299 4.0 GoC - Goldston 6 NC-ST-03-07 Ridenhour, Robert Barrie; Ridenhour, Billy Joe Stanly 35.369518 -80.360506 18.1 BaB - Badin 6 NC-ST-04-01 Henry W. Anderson Living Trust Stanly 35.236256 -80.306856 26.8 BaB - Badin 7 NC-ST-04-02 Lynette W. Anderson Living Trust Stanly 35.236256 -80.306856 12.8 GoC - Goldston 7 NC-ST-04-03 Henry W. Anderson Living Trust Stanly 35.233820 -80.305616 6.9 BaB - Badin 7 NC-ST-04-04 Lynette W. Anderson Living Trust Stanly 35.231576 -80.307522 8.9 BaB - Badin 7 NC-ST-04-05 Lynette W. Anderson Living Trust Stanly 35.229633 -80.309558 6.7 MhB - Misenheimer 7 NC-ST-15-01 Clyde Keith Hinson Family Trust Stanly 35.241094 -80.284413 3.7 GoC - Goldston 8 W00016247 Version 3.3 Attachment B Page 3 of 4 ATTACHMENT B - Approved Land Application Sites Synagro Central, LLC Certification Date: July 31, 2017 Permit Number: WQ0016247 Version: 3.3 Field/ Site Owner Lessee County Latitude Longitude Net Acreage Dominant Soil Series Footnotes NC-ST-15-02 Clyde Keith Hinson Family Trust Stanly 35.244034 -80.282976 9.2 Ball - Badin 8 NC-ST-15-03 Clyde Keith Hinson Family Trust Stanly 35.241001 1 .80.281718 1.9 BaB - Badin 8 Total jot Stanly County 295.0 Total 1,036.5 1-13. See Figures Ito 13, respectively. 14. A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet of the residence owned by Frances Little Efird of 9803 Stogner-Little Road, Oakbom, NC 28129, regardless of whether a surface or a subsurface application method is used. 15. A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet of the residence owned by Harry Stogner of 9905 Stogner-Little Road, Oakboro, NC 28129, regardless of whether a surface or a subsurface application method is used. 16. A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet of the residence owned by Michael D. Marlon of 9953 Stogner-Little Road, Oakboro, NC 28129, regardless of whether a surface or a subsurface application method is used. 17. A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet of the residence owned by Mickey S. Edwards and Teresa M. Edwards of 400 Eagle Nest Road, Columbus, NC 28722, regardless of whether a surface or a subsurface application method is used. 18. A reduced setback from a residence under separate ownership has been approved for this land application site. Residuals may be land applied within 100 feet of the residence owned by Louise Edwards of 332 Eagle Nest Road, Columbus, NC 28722, regardless of whether a surface or a subsurface application method is used. WO0016247 Version 3.3 Attachment B Page 4 of 4 APPLICATION MAP I11111INd\I21 APPLICATION AREA F01 UNSUITABLE AREA — — — — — — PRIVATE ROAD —� WATER — — — — STREAM ■� ONSITE HOUSE — — — DRAIN OFFSITE HOUSE �--— FENCE ❑ OUTBUILDING PROPERTY LINE WELL O SOIL BORING The compliance boundary is established either 250 ft from the residuals application area or 50 feet within in the property boundary, whichever Is closest to the application area. The review boundary is established midway between the compliance boundary and the perimeter of the residuals application area. All locations are approximate. GRAPHIC SCALE 1" = 660' 660' 0 660' , Figure 9 NC-CD-02 Fields 1-3 a z r M APPLICATION MAP LEGEND APPLICATION AREA PRIVATE ROAD STREAM DRAIN 3( X �6 FENCE PROPERTY LINE OO SOIL BORING UNSUITABLE AREA WATER ONSITE HOUSE OFFSITE HOUSE OUTBUILDING WELL The compliance boundary is established either 250 ft from the residuals application area or 50 feet within in the property boundary, whichever is closest to the application area. The review boundary is established midway between the compliance boundary and the perimeter of the residuals application area. All locations are approximate. GRAPHIC SCALE V = 660' 660' o a6T Figure 10 NC-CD-02 Fields 4-5 APPLICATION MAP LEGEND APPLICATION AREA UNSUITABLE AREA — — — — — — PRIVATE ROAD O WATER — — — — STREAM ■ ONSITE HOUSE — — — DRAIN OFFSITE HOUSE FENCE ❑ OUTBUILDING PROPERTY LINE WELL OO SOIL BORING The compliance boundary is established either 250 ft from the residuals application area or 50 feet within in the property boundary, whichever is closest to the application area. The review boundary is established midway between the compliance boundary and the perimeter of the residuals application area. All locations are approximate. GRAPHIC SCALE 1" = 660' 660' 0 66V Figure 11 NC-CD-15 Field 1 APPLICATION MAP I Gr_Gnln I cI APPLICATION AREA V01 UNSUITABLE AREA ---n—n—�— PRIVATE ROAD O WATER — — — — STREAM ■ ONSITE HOUSE — — — DRAIN OFFSITE HOUSE X X X— FENCE OUTBUILDING PROPERTY LINE WELL (� SOIL BORING The compliance boundary is established either 250 It from the residuals application area or 50 feet within in the property boundary, whichever is closest to the application area. The review boundary is established midway between the compliance boundary and the perimeter of the residuals application area. All locations are approximate. GRAPHIC SCALE 1 " = 660' 660' 0 660' Figure 12 NC-PO-06 Fields 1-3 APPLICATION MAP 1 r KIM I cI APPLICATION AREA F01 UNSUITABLE AREA — —�— — —�— PRIVATE ROAD � WATER — — — — STREAM _.� ONSITE HOUSE — — — DRAIN OFFSITE HOUSE X X: X FENCE ❑ OUTBUILDING PROPERTY LINE WELL SOIL BORING The compliance boundary is established either 250 ft from the residuals application area or 50 feet within in the property boundary, whichever is closest to the application area. The review boundary is established midway between the compliance boundary and the perimeter of the residuals application area. All locations are approximate. GRAPHIC SCALE 1" = 660' 660' 0 660 Figure 13 NC-PO-07 Fields 1-2 DWG State of North Carolina Department of Environment and Natural Resources Division of Water Resources Dlvislon of Water Resources SETBACK WAIVER AGREEMENT (FOR RESIDUALS PROGRAM) FORM: SWA 08-13 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 or for an electronic version of this form, visit the Land Application Unit (LAU) web site at: http: //portal. ncdenr. org/web/wa/ads/lau General — This document is an agreement between the Applicant and the owner(s) of the property adjacent to the land application site(s) to allow setback reduction for habitable residences or place of public assembly not owned by the permittee or not to be maintained as part of project site(s) in accordance with 15A NCAC 02T 1108(b)(2)[for habitable residences or place of public assembly only]. Do not submit this agreement for review without a corresponding application form (FORM: RLAP 08-13). A. Setback Waiver Agreement: ❑ Submit the completed and appropriately executed Setback Waiver Agreement (FORM: SWA 08-11) 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 property from which a waiver is being sought. ❑ Any other setbacks required by 15A NCAC 02T .1108, other than those referenced above, cannot be waived through execution of this agreement. ❑ A copy of the completed and executed agreement must be provided to the property owner. AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 02T1 .1108(b)(2)(habixable residences) The undersigned property owner hereby permits: . 1 I LVJ — n Applicant's name: Applicable Field ID: �P'O — 4 3" — Q Y hereinafter referred to as the Permittee, to land apply residuals within 100 feet (i.e., cannot be less than 100 feet) of the residence or place of public assembly located at the following: Location address of property: Y 0 0E-0- � I Q N i S'� tQ p 0. CV City: State: N C Zip: pip Ta-a+ This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for the residuals land application program and shall be renewed each time this permit is renewed. In addition, this Agreement shall only remain in effect for as long as the undersigned property owner owns the property described herein. The undersigned property owner agrees to abide by this Agreement until such time as written notification, given 30 calendar days ' -advance, modifies or cancels this Agreement. 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 land apply residuals to land application site(s) as specified herein. Property owner name: Signature: r T 31°11 Ir] FORM: SWA 08-13 Page 1 of 1 DWR State of North Carolina Department of Environment and Natural Resources Division of Water Resources Division of Water Resources SETBACK WAIVER AGREEMENT (FOR RESIDUALS PROGRAM) FORM: SWA 08-13 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 or for an electronic version of this form, visit the Land Application Unit (LAU) web site at: htt/portal ncdenr or¢/web/wg/aps/lau General — This document is an agreement between the Applicant and the owner(s) of the property adjacent to the land application site(s) to allow setback reduction for habitable residences or place of public assembly not owned by the permittee or not to be maintained as part of project site(s) in accordance with 15A NCAC 02T 1108(b)(2)ffor habitable residences or place of public assembly only]. Do not submit this agreement for review without a corresponding application form (FORM: RLAP 08-13). A. Setback Waiver Agreement: ❑ Submit the completed and appropriately executed Setback Waiver Agreement (FORM: SWA 08-11) 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 property from which a waiver is being sought. ❑ Any other setbacks required by 15A NCAC 02T .1108, other than those referenced above, cannot be waived through execution of this agreement. ❑ A copy of the completed and executed agreement must be provided to the property owner. AGREEMENT TO WAIVE THE SETBACK REQUIRED BY 15A NCAC 02T .1108(b)(2)(habitable residences) The undersigned property owner hereby permits: N\X-k-�t Applicant's name: S-_(Ya Applicable Field ID: �:, 0 ` al - O f LAS hereinafter referred to as the Permittee, to land apply residuals within feet (i.e., cannot be less than 100 feet) of the residence or place of public assembl located at the following: Location address of property: 3 7� L, L�C.1 I e- /�(LS t- City: 01_O 1 l� A r �U S State: NE-- zip: o16J1 a This Agreement shall remain in effect for the length of the Division of Water Quality's (Division) permit for the residuals land application program and shall be renewed each time this permit is renewed. In addition, this Agreement shall only remain in effect for as long as the undersigned property owner owns the property described herein. The undersigned property owner agrees to abide by this Agreement until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement. el 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 land apply residuals to land application site(s) as specified herein. Property owner Signature: Date: 's,-: -/ FORM: SWA 08-13 Page 1 of 1