WQ0022307_Final Permit_20161214

Water Resources
ENVIRONMENTAL QUALITY
PAT MCCRORY
Governor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Director
December 14, 2016
STEVEN M. AND RITA B. BARNHARDT
417 STONEWYCK DRIVE
BURLINGTON, NORTH CAROLINA 27215
Dear Mr. and Mrs. Barnhardt:
Subject: Permit No. WQ0022307
Heritage Harbor Lot D SFR
Single -Family Residence
Wastewater Irrigation System
Person County
In accordance with your permit renewal request received June 16, 2016, we are forwarding
herewith Permit No. WQ0022307 dated December 14, 2016, to Steven M. and Rita B. Barnhardt for the
construction and operation of the subject single-family residence wastewater treatment and irrigation
facilities.
This permit shall be effective from the date of issuance until November 30, 2021, shall void Permit
No. WQ0022307 issued November 9, 2007, and shall be subject to the conditions and limitations as
specified therein. An extension shall be requested at least six months prior to the expiration of this
permit. Upon receipt of the request, the Commission will review the adequacy of the facility described
therein and, if warranted, will extend the permit for such period of time and under such conditions and
limitations as it may deem appropriate.
Please pay particular attention to the operation and maintenance requirements listed in Section III
for they may differ from the previous permit issuance. Failure to establish an adequate system for collecting
and maintaining the required operational information shall result in future compliance problems. Also note
that Condition VI.6. requires the Permittee to retain a set of Division approved plans and specifications for
the life of the facilities permitted herein.
Please note the following permit conditions have been removed since the last permit issuance
dated November 9, 2007:
➢ Old Conditions I.5., 1.6., and 1.8. —Conditions have been removed as they are covered under
15A NCAC 02T .0605 and 15A NCAC 18A .1900 Sewage Treatment and Disposal Systems.
➢ Old Condition I.11.h. — This setback was inadvertently added during the previous permit
issuance.
Please note the following permit conditions are new since the last permit issuance dated
November 9, 2007:
➢ Condition HA. — This condition includes information about the wastewater irrigation field.
Stale 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 6464

Mr. Steven M. Barnhardt and Mrs. Rita B. Barnhardt
December 14, 2016
Page 2 of 2
➢ Condition 11.7. — This condition establishes the compliance boundary at the property boundary
in accordance with 15A NCAC 02L .0107(i).
➢ Condition 11.8. — This condition establishes the review boundary midway between the
compliance boundary and the disposal area in accordance with 15A NCAC 02L .0108.
➢ Condition IL9. — This condition requires the Permittee to apply for a permit modification to
establish a new compliance boundary if any sale or transfer of property affects the existing
compliance boundary.
➢ Condition IV.2.c. — This condition requires the Permittee to notify the Division any time self -
monitoring indicates the facility has gone out of compliance with its permit limitations.
➢ Condition IV.2.d. — This condition requires the Permittee to notify the Division any time there
is ponding in or runoff from the irrigation sites.
➢ Condition VI.7. — This condition requires that the Permittee shall maintain this permit until all
permitted facilities herein are properly closed or permitted under another permit issued by the
appropriate permitting authority.
➢ Condition VI.8. — This condition states that the permit is subject to revocation or unilateral
modification upon 60 days' notice from the Division Director, in whole or part for the
requirements listed in I SA NCAC 02T .0110.
➢ Condition VI.9. — This condition requires that unless the Division Director grants a variance,
expansion of the permitted facilities contained herein shall not be granted if the Permittee
exemplifies any of the criteria. in 15A NCAC 02T .0120(b).
If any parts, requirements or limitations contained in this permit are unacceptable, the Permittee
has the right to request an adjudicatory hearing upon written request within 30 days following receipt of
this permit. 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, NC 27699-6714, Unless such demands are made, this permit shall be final and binding.
If you need additional information concerning this permit, please contact Alice M. Wessner at (919)
807-6425 or alice.wessner ncdenr. ov.
Sincerely,
R
0 -. Jay Zimmerman, P.G., Director
Division of Water Resources
cc: Person County Health Department, Harold Kelly, Environmental Health Supervisor,
bkeWpersoncounty.net (Electronic Copy)
Raleigh Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Digital Permit Archive (Electronic Copy)
Central Files

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
Steven M. and Rita B. Barnhardt
Person County
111910 11011
construction and operation of a 480 gallon per day (GPD) single-family residence wastewater treatment
and irrigation facility consisting of:
a 1,250 gallon baffled septic tank; two 210 square foot (ft) sand filters; a chlorine contact basin; a 1,578
gallon storage tank; a 2,440-gallon pump tank; approximately 485 linear feet (LF) of 3/4-inch force main; a
0.23 acre spray irrigation area with five nozzles; and all associated piping, valves, controls, and
appurtenances
to serve the single-family residence at Heritage Harbor Lot D, Semora, NC 27343, with no discharge of
wastes to surface waters, pursuant to the application received and in conformity with the project plans,
specifications, and other supporting data subsequently filed and approved by the Department of
Environmental Quality and considered a part of this permit.
This permit shall be effective from the date of issuance until November 30, 2021, shall void Permit No.
WQ0022307 issued November 9, 2007 and shall be subject to the following specified conditions and
limitations:
I. SCHEDULES
1. Upon completion of construction and prior to operation of this permitted facility, a certification
(attached) shall be submitted from a licensed North Carolina Professional Engineer certifying that the
permitted facility has been installed in accordance with this permit, Division approved plans and
specifications, and other supporting documentation, including the location of all monitoring wells as
applicable. If this project is to be completed in phases and partially certified, the Permittee shall retain
the responsibility to track further construction approved under the same permit, and shall provide a
final certificate of completion once the entire project has been completed. Mail the Certification to the
Division of Water Resources, Water Quality Permitting Section, 1617 Mail Service Center, Raleigh,
NC 27699-1617. [ 15A NCAC 02T ..0116]
2. The Raleigh Regional Office, telephone number [phone], shall be notified at least 48 hours in
advance (excluding weekends and holidays) of operation of the installed facilities such that an in -place
inspection can be made. Notification to the regional supervisor shall be made from 8:00 a.m. until 5:00
p.m. on Monday through Friday, excluding State Holidays. [15A NCAC 02T A108 (b)(2)]
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No later than six months prior to the expiration of this permit, the Permittee shall request renewal of
this permit on official Division forms. Upon receipt of the request, the Division will review the
adequacy of the facilities described therein, and if warranted, will renew the permit for such period of
time and under such conditions and limitations as it may deem appropriate. Please note Rule 15A
NCAC 02T .0105(d) requires an updated site map to be submitted with the permit renewal application.
[15A NCAC 02T .0105, 02T .0109, 02T .0115(c)]
4. If a public or community sewage system is or becomes available, the subject single-family residence
wastewater treatment and irrigation facilities shall be closed and all wastewater shall be discharged into
the public or community sewage system within 180 days of its availability. Prior to the initiation of
these connection activities, appropriate Division approval shall be received. [15A NCAC 02T .0607]
II. PERFORMANCE STANDARDS
1. The subject non -discharge facilities shall be effectively maintained and operated at all times so there is
no discharge to surface waters, nor any contravention of groundwater or surface water standards. In
the event the facilities fail to perform satisfactorily, including the creation of nuisance conditions due
to improper operation and maintenance, or failure of the irrigation areas to adequately assimilate the
effluent, the Permittee shall take immediate corrective actions including Division required actions, such
as the construction of additional or replacement wastewater treatment or disposal facilities. [15A
NCAC 02T .0108(b)(1)]
2. This permit shall not relieve the Permittee of their responsibility for damages to groundwater or surface
water resulting from the operation of this facility. [15A NCAC 02B .0200, 02L .4100]
3. Application rates, whether hydraulic, nutrient or other pollutant, shall not exceed those specified in the
following table:
TABLE I — APPLICATION LIMITATIONS
Field
Parameter
Hourly Rate
Yearly Max
Units
1
01284 — Non -Discharge Application Rate
0.25
30.3
inches
[15A NCAC 02T .06050)]
4. The subject facility has been approved to land apply wastewater effluent on the following fields:
TABLE 2 — IRRIGATION AREA INFORMATION
Field
Owner
County
Latitude
Longitude
Net Acreage
Dominant
Soil Series
1
Steven M. and Rita B.
person
36.51879P
-79.0703900
0.23
WkB Wilkes Loam, 2-
Barnhardt
8% slopes
[G.S. 143-215.11
5. The Operation and Maintenance Agreement (attached) between the Permittee and the Division of Water
Resources is incorporated herein by reference and shall be a condition of this permit. Noncompliance
with the terms of the Operation and Maintenance Agreement shall subject the Permittee to all sanctions
provided by North Carolina General Statutes § 143-215.6A to § 143-215.6C for violation of or failure
to act in accordance with the terms and conditions of this permit. [ 15A NCAC 02T .0115 (2)]
6. The irrigation system shall be connected to a rain or moisture sensor, which shall indicate when effluent
application is not appropriate in accordance with Conditions IIIA. and IIl.5. of this permit. [15A NCAC
02T .0605(o)]
7. The compliance boundary is established at the property boundary. Any exceedance of standards at the
compliance boundary shall require action in accordance with 15A NCAC 02L .0106. [15A NCAC 02L
A 107(i)]
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8. The review boundary is established midway between the compliance boundary and the effluent disposal
area. Any exceedance of groundwater standards at the review boundary shall require action in
accordance with 15A NCAC 02L .0106. [15A NCAC 02L .0108]
9. The Permittee shall apply for a permit modification to establish a new compliance boundary prior to
any sale or transfer of property affecting a compliance boundary. [15A NCAC 02L .0107(c)]
10. The facilities permitted herein shall be constructed according to the following setbacks:
a. The setbacks for irrigation sites permitted under 15A NCAC 02H .0200 shall be as follows (all
distances in feet):
i. Any habitable residence or place of public assembly under separate ownership: 400
ii. Surface waters: 100
iii. Any well with exception of monitoring wells: 100
iv. Any property line: 150
v. Public right of way: 50
1 Per setback waivers recorded in the Person County Register of Deeds, setbacks from the wetted
area to any property line has been reduced for the following:
Parcel No.
Deed Book / Page
Setback
Easement
9918
940 / 125
100 feet
50 feet
9919
940 / 121
0 feet
150 feet
[15A NCAC 02H .02190)]
b. The setbacks for storage and treatment units permitted under 15A NCAC 02H .0200 shall be as
follows (all distances in feet):
L Any well with exception of monitoring wells: too
ii. Any property line: 50
[15A NCAC 02H .02190)]
III. OPERATION AND MAINTENANCE REQUIREMENTS
1. The facilities shall be properly maintained and operated at all times. The facilities shall be effectively
maintained and operated as a non -discharge system to prevent the discharge of any wastewater resulting
from the operation of this facility. The Permittee shall maintain an Operation and Maintenance Plan
pursuant to 15A NCAC 02T .0604(f). [15A NCAC 02T .0604(f)]
2. Upon the Water Pollution Control System Operators Certification Commission's (WPCSOCC)
classification of the subject non -discharge facilities, in accordance with 15A NCAC 08G .0200 the
Permittee shall designate and employ a certified operator in responsible charge (ORC) and one or more
certified operator(s) as back-up ORC(s). The ORC or their back-up shall visit the facilities in
accordance with 15A NCAC 08G .0200, and shall comply with all other conditions specified in the
previously cited rules. [ 15A NCAC 02T .0117]
A suitable year round vegetative cover shall be maintained at all times, such that crop health is
optimized, allows for even distribution of effluent and allows inspection of the irrigation system. [ 15A
NCAC 02T .0108(b)(1)]
4. Adequate measures shall be taken to prevent effluent ponding in or runoff from the irrigation sites listed
in Condition II.4. [15A NCAC 02T .0605(o)]
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5. Irrigation shall not be performed during inclement weather or when the ground is in a condition that
will cause ponding or runoff. [15A NCAC 02T .0605(o)]
6. Only effluent from the single-family residence at Heritage Harbor Lot D SFR, Semora, NC 27343 shall
be irrigated on the sites listed in Condition 11.4. [G.S. 143-215.1]
No automobiles or machinery shall be allowed on the irrigation sites except during equipment
installation or while maintenance is being performed. [15A NCAC 02T .0108(b)(1)]
8. Public access to the irrigation sites and wastewater treatment facilities shall be prohibited. Fencing
shall be provided to prevent access to the irrigation site (minimum 2-strand wire) and treatment units
shall be secured with locks on all tank accesses and control panels. [15A NCAC 02T .0605(i)]
9. The residuals generated from the wastewater treatment facilities shall be disposed or utilized in
accordance with 15A NCAC 02T .1100. [ 15A NCAC 02T .l 100].
10. Diversion or bypassing of untreated or partially treated wastewater from the treatment facilities is
prohibited. [ 15A NCAC 02T .0605(f)]
11. Pump/dosing tanks shall have audible and visual alarms external to any structure. [15A NCAC 02T
.0605(n)]
12. Any excavation into bedrock shall be lined with a 10 millimeter (mm) synthetic liner. [15A NCAC
02T .0605(d)]
13. The Permittee is responsible for the operation and maintenance of the entire treatment and disposal
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed. The septic tank effluent filter
shall be checked and cleaned at the same frequency as the septic tank. [15A NCAC 18A .1900,
02T .0605]
b. The tablet chlorinator shall be checked weekly. Wastewater grade chlorine tablets (calcium
hypochlorite) shall be added as needed to provide proper chlorination. Pool chlorine tablets shall
not be used. [15A NCAC 02T .0605(1)]
c. The storage, pump, and alarm systems shall be inspected monthly. The scum layer in the storage
and pump tanks shall be removed at the same interval as the septic tank is cleaned out. [ 15A NCAC
02T .0108(b)(1)]
d. The system shall be inspected monthly to make certain of the proper operation of the spray heads,
that the system is free of leaks, that the vegetative growth allows a proper spray pattern, that the
soil is assimilating the disposed treated wastewater with no surface runoff, and that no objectionable
odors are being generated. [ 15A NCAC 02T .0108(b)(1)]
14. A homeowner's association shall be formed for the purpose of road easements for all lots. The
association shall be responsible for any damage and repairs necessitated by the failure of any of the
force mains serving the off -site spray lots. The Engineer's Certification shall be evidence that this
condition has been met. f 15A NCAC 02T .0108(b)(1)]
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IV. MONITORING AND REPORTING REQUIREMENTS
V.
1. Any Division required monitoring (including groundwater, plant tissue, soil and surface water analyses)
necessary to ensure groundwater and surface water protection shall be established, and an acceptable
sampling reporting schedule shall be followed. [15A NCAC 02T .0108(c)]
2. Noncompliance Notification:
The Penmittee shall report by telephone to the Raleigh Regional Office, telephone number (919) 791-
4200, as soon as possible, but in no case more than 24 hours, or on the next working day following the
occurrence or first knowledge of the occurrence of any of the following:
Any process unit failure (e.g., mechanical, electrical, etc.), due to known or unknown reasons,
rendering the facility incapable of adequate wastewater treatment.
b. Any facility failure resulting in a by-pass directly to receiving surface waters
c. Any time self -monitoring indicates the facility has gone out of compliance with its permit
limitations.
d. Ponding in or runoff from the irrigation sites.
Any emergency requiring immediate reporting (e.g., discharges to surface waters, imminent failure of
a storage structure, etc.) outside normal business hours shall be reported to the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone]. Persons
reporting such occurrences by telephone shall also file a written report in letter form within five days
following first knowledge of the occurrence. This report shall outline the actions taken or proposed to
betaken to ensure the problem does not recur. jl5A NCAC 02T .0105(1)]
1. The Permittee shall provide adequate inspection and maintenance to ensure proper operation of the
wastewater treatment and irrigation facilities. [15A NCAC 02T .0108(b)]
2. The Permittee or their designee shall inspect the wastewater treatment and irrigation facilities to prevent
malfunctions, facility deterioration and operator errors resulting in discharges, which may cause the
release of wastes to the environment, a threat to human health or a public nuisance. The Pennittee shall
maintain an inspection log that includes, at a minimum, the date and time of inspection, observations
made, and any maintenance, repairs, or corrective actions taken. The Permittee shall maintain this
inspection log for a period of five years from the date of the inspection, and this log shall be made
available to the Division upon request, [15A NCAC 02T ,0108(b)]
3. Any duly authorized Division representative may, upon presentation of credentials, enter and inspect
any property, premises or place on or related to the wastewater treatment and irrigation facilities
permitted herein at any reasonable time for the purpose of determining compliance with this permit;
may inspect or copy any records required to be maintained under the terms and conditions of this permit,
and may collect groundwater, surface water or leachate samples. [G.S. 143-215.3(a)(2)]
VI. GENERAL CONDITIONS
1. Failure to comply with the conditions and limitations contained herein may subject the Permittee to an
enforcement action by the Division in accordance with North Carolina General Statutes 143-215.6A to
143-215.6C. [G.S. 143-215.6A to 143-215.6C]
2. This permit shall become voidable if the permitted facilities are not constructed in accordance with the
conditions of this permit, the Division approved plans and specifications, and other supporting
documentation. [ 15A NCAC 02T .01101
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3. This permit is effective only with respect to the nature and volume of wastes described in the permit
application, Division approved plans and specifications, and other supporting documentation. No
variances to applicable rules governing the construction or operation of the permitted facilities are
granted, unless specifically requested and approved in this permit pursuant to 15A NCAC 02T .0105(n).
[G. S. 14.-215.1 ]
4. The issuance of this permit does not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances, which may be imposed by other jurisdictional government agencies
(e.g., local, state, and federal). Of particular concern to the Division are applicable river buffer rules in
15A NCAC 02B .0200; erosion and sedimentation control requirements in 15A NCAC Chapter 4 and
under General Permit NCGO10000; any requirements pertaining to wetlands under 15A NCAC 02B
.0200 and 02H .0500; and documentation of compliance with Article 21 Part 6 of Chapter 143 of the
General Statutes. [15A NCAC 02T .0105(c)(6)]
5. In the event the permitted facilities change ownership or the Permittee changes their name, a formal
permit modification request shall be submitted to the Division. This request shall be made on official
Division forms, and shall include appropriate property ownership documentation and other supporting
documentation as necessary. The Permittee of record shall remain fully responsible for maintaining
and operating the facilities permitted herein until a permit is issued to the new owner. [15A NCAC
02T .0104]
6. The Permittee shall retain a set of Division approved plans and specifications for the life of the facilities
permitted herein. [15A NCAC 02T .0108(b)(1)]
7. The Permittee shall maintain this permit until all permitted facilities herein are properly closed or
permitted under another permit issued by the appropriate permitting authority. (15A NCAC 02T
.01050)]
This permit is subject to revocation or unilateral modification upon 60 days notice from the Division
Director, in whole or part for the requirements listed in 15A NCAC 02T .0110. [ 15A NCAC 02T .0110]
9. Unless the Division Director grants a variance, expansion of the permitted facilities contained herein
shall not be granted if the Permittee exemplifies any of the criteria in 15A NCAC 02T .0120(b). [ I5A
NCAC 02T.0120]
10. The Permittee shall pay the annual fee within 30 days after being billed by the Division. Failure to pay
the annual fee accordingly shall be cause for the Division to revoke this permit. [15A NCAC 02T
.0105(e)(3)]
Permit issued this the 14' day of December 2016
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
FS. Jay Zimmerman, P.G., Director
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number WQ0022307
WQ0022307 Version 3.0 Shell Version 151201 Page 6 of 7

Permit No. WQ0022307 Single -Family Residence Wastewater Irrigation System
Steven M. and Rita B. Barnhardt December 14, 2016
Heritage Harbor Lot D SFR Person County
ENGINEERING CERTIFICATION
❑ Partial ❑ Final
In accordance with 15A NCAC 02T .0116, I, _, as
a duly registered Professional Engineer in the State of North Carolina, having the Permittee's authorization
to ❑ periodically ❑ weekly ❑ fully observe the construction of the permitted facility, hereby state to the
best of my abilities that due care and diligence was used in the observation of the construction, such that
the facility was built within substantial compliance and intent of this permit, the Division approved plans
and specifications, and other supporting documentation.
❑ Any variation to this permit, the Division approved plans and specifications, and other supporting
documentation has been documented in the attached as -built drawings, and shall serve as the
Permittee's minor modification request to amend the permit accordingly.
Provide a brief narrative description of any variations:
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
By Courier/Special Delive :
512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
WQ0022307 Version 3.0 Shell Version 151201
Page 7 of 7

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
DWFv_ 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE WASTEWATER fRRIGATION SYSTEMS
OPERATION AND MAINTENANCE AGREEMENT
Division of Water Resources FORM: SFRW'A'I5 O&NI 03-13
Permit No. Z County:
Property owiler(s) as appearing on the recorded deed: v �j j112,,A �� J� --
Mailing address: i G PQi C_j� '�;,t l�2 "Ll 7 �,.� /[terC Z'7 Z ! :5
Facility address:
irrigation Method: X SPRAY ❑ DR[P
I / We agree to operate and maintain the single family residence wastewater treatment and irrigation system as follows:
1. The Perrrittee is responsible for the operation and maintenance: of the entire wastewater treatment and irrigation
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed.
b_ The septic tank effluent filter shall be checked and cleaned annually.
c. Accessible sand fitter surfaces shall be raked and leveled every six months and any vegetative growth shall be
remeved manually.
d. C The tablet chlorinator shall be checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be
added as needed to provide proper chlorination (pool chlorine tablets shall not be used), OR
❑ The ultraviolet disinfection unit shall be checked weekly. The laMP(s) and quartz sleeve(s) shall be
cleaned or replaced as needed to ensure proper disinfection.
e. Ali pump and alarm systems shall be inspected monthly.
f. The irrigation system shall be inspected monthly to ensure that the system is free of leaks, that all irrigation
equipment is operating as designed, that vegetative growth does not interfere with the system inspection or
operation, that the soil is assimilating the disposed treated wastewater with no visible runoff or ponding, and
that no objectionable odors are being generated.
2. Failure to pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T
.0I 05 (e)(3 ).
3. The Perrraittee's failure to properly operate this system is subject to a penalty up to $25,000 per day.
a. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void
the permit.
All owners apflearing on the le ativ recorded iwo-yerty deed shall sign this overation & Maintenance Agreement
I / We understand the above requirements and agree to these terns as part of the issued permit.
Owner Signature: Date:
Owner Signature: Date:
FORM: SFRWWIS O&M 08-13 Page I of I
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b tONTA R. WILSON
WGIS ER OF UEEOS
Book 410 Pa a 121
ill IIIIIIIIIIIIIIIII�llllllllll 111
2016
State of North Carolina
Department of Environmental Quality '
Division of Water Resources
NON -DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM Am)' BE PHOTOCOPIED FOR USE AS AN ORIGIN 4L)
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.
Far more lnfrnnratir�rr rIr for ara electrortir rersicrr� of thrs fr�rrx, vi.ril our xeh SIt(3 a,:
!nt or tul�izcclern..ryt�i� e(/r_? �u'rtnnllcgilnris.
NSTRUCTIONS TO THE APPLICANT:
✓ Do not submit this form for review without a corresponding Mon -Discharge Permitting 11
Any charrges to this form will result in the application package being returned. � n;� application form.
Any other setbacks required by I SA NCAC Subchapter 02T other' than those referenced below-_ cannot be waived
through execution oftl)is form.
✓ A copy of the completed and appropriately executed fibrin roust be
-- - -- r. provided to the prope
rty owner.
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
I5A NCAC 02T .0506(a), .0506(b), .0606(a), .0706(a) and .1006(a)
The undersigned property owner(s) hereby permits:
Applicant's name: Steven M. &Rita B. Barnhardt
Complete mailing address of applicant; Her_ . itag. - rbor I,ot D or„ Clearwater Ln- Parcel No- g_ 9241
City: Semora State_ NC —��
- Zip: 27343
Telephone number: (336 263-4245
Facsimile number:
Hereinafter referred to as the Permittee, to (check all that apply):
® Non• -Discharge disposal of wastewater effluent within 0 feet of the property tine,
❑ 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
feel of the identified residence_
FORM: NDWSW 10-16
Pagel or2

BOOK 990 PAGE 122 368021
The waived setbacks apply as shown on the attached map and located at the following:
Location address of property: Heritage Harbor Lot C on Clearwater L n. Parcel No, 9914
City: Semora State: NC
Zip: 27343
® 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 reco_ rd this waiver form with_the aA�ro riate Re isrer of
Deeds and provide the Permittee and Division of Water RP.Qn,,rnAe .x,:«, 7 W _ -. .
Property owners) name(s):
Signature:
Signature:
FORTH CA.ROLINA, c_ COUNTY
a Notary Public for 1County., North Carolina,
do hereby certify that :- e .-. h.n
personally appeared before n1c this day and
acknowledged the dire execution of the'foregoing instrument.
Witness my hand and official seal this the '2 ; clay of
SE4!
a® RIP r��1j%40
®mom` `� 602 sir
0\,cknc
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FORM: NDWSW 10-16
Qture of Notary Pub
My commission Expires
Document sltu�tis proof/acknou ledgement betbre
officer authorised to take proof/acknom fedgement:
acknocvlcdgemen includes Officer's signature.
cnmirni e. pirate n da si - a3 seal, i,'required.
ilson, ersort C OL! 14 Register ol' Deeds
Page 2 o F 2

3�o 7
FILED in PERSON County. NC
an Doc 00 2016 it 0915.116 AM
b : IONYA R. WILSON
GISTER OF DEEDS
aok 940 Pa a 125
III 111111111111111111111111111 III
`tm
State of North Carolina
�5 y b
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTEWATER SYSTEM WAIVER
(THIS FORM MAYBE PHO-1-000P1ED FOR USE AS AN ORICI.V.4 L)
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 n7formutron urfvr an electronic rerrion of this fibrin, visit our ,j,eh sire at:
lyuz�: portai.iacde�rr.�»;�ueGria/u s.�IAulunnlicatfal7.s.
INSTRUCTIONS TO THE APPLICANT- _.
✓ Do not submit this form for review without a con-espondink Non -Discharge Permitting Unit application form.
Any changes to this form will result in the application package being returned.
✓ Any other setbacks required by c
15A NCAC Subchapter 02T other than those referenced below_ annot be waived
through execution of this form.
✓ A copy of the completed and appropriately executed form must be provided to the propel-ty otivne:-.
AGREEMENT To WAIVE SETBACKS AS REQUIRED BY
15A NCAC 02T ,0506(a), .0506(b), .0606(a), .0706(a) and .I006(a)
The undersigned property owner(s) hereby permits:
Applicant's name: Steven M. & Rita_a. Barnhardt.
Complete mailing address of applicant: Herit e_lLlarbor Lot Q on Clearwater Ln. Parcel No. 9920
City: Sernora _ State: NC ^ — —
Zip: 27343
Telephone number: [phone]
Facs"nile number: (�_)
Thereinafter referred to as the l'ermittee, to (check all that apply):
® Non -Discharge disposal of wastewater effluent within 100 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.- N DMIS W 10-16
Page # 01'2

BOOK 910 PAGE 126 36803
The waived setbacks apply as sbowu on the attached map and IOCated at the following:
Location address of property: Heritage Harbgr Lat on Clearwater Ln. Parcel No. 41$
State: NC_ Zip: 27343 _
® 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
Aarreement and do hereby grant permission to the Permittee to dispose of wastewater effluent or construct wastewater
treatment traits as specified herein. I further.agree thy@ wili_rec:ord this wa.yer form with the ap�ro riaie Re inter of
L7eeds and, rovideths P;nnittee aand Nvision # Water Resources with documentation of such.
Property owners) na---
Signature:'
.._�.._ .Date: qL
E4,
Signature: Date: I!K
NORTH CAROLINA,---w...-j-Ct COL'}rTy
i A 'wc[ " l0Y Notary Public; For U �
County, Ntarth Carolina,
do hereby certiA, that - �
ackno,. iedQed the due eLiecu rat f4anto$prt
persorallY appeared before the this day and
reo
�oinQ it15t melt.
Witness in) hand and official seal this the
SEAL
M
.Wake
MY2p
r;ACM: NL))A/SW i()•16
J�
Signature a . 'ofary P !ic
ITT cnrrrmissiorr erpirer LQ - 's
Document show, proof lacknowledgeni nt before
otiicer authorized to take proof /acknowledgcment:
ackaowledgt�ment includesoffcer'-,sienature.
com on eapirau m d trial sea . if -quired.
t u lson. Pcr%oTn County Register of Deeds
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