WQ0033896_Final Permit_20170130

Water Resources
ENVIRONMENTAL QUALITY
January 30, 2017
ELIZABETH B. FussELL
POST OFFICE BOX 2507
SURF CITY, NORTH CAROLINA 28445-2507
Dear Ms. Fussell:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
S. JAY ZIMMERMAN
Director
Subject: Permit No. WQ0033896
557 Belt Rd. SFR
Single -Family Residence
Wastewater Irrigation System
Pender County
In accordance with your permit renewal request received January 23, 2017, we are forwarding
herewith Permit No. WQ0033896 dated January 30, 2017, to Elizabeth B. Fussell for the continued
operation of the subject single-family residence wastewater treatment and irrigation facilities.
This permit shall be effective from the date of issuance until December 31, 2021, shall void Permit
No. WQ0033896 issued September 18, 2009, 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,
as well as the monitoring requirements listed in Section N, 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
Permittce to retain a set of Division approved plans and specifications for the life of the facilities permitted
herein.
Please note the following permit conditions are new since the last permit issuance dated
September 18, 2009:
➢ Condition 11.4. — This condition describes the effluent application area.
➢ Condition I1.7. — This condition establishes a compliance boundary at the property line.
➢ Condition I1.8. — This condition establishes a review boundary around the application area.
➢ Condition 1I.9. — This condition requires applying for a permit modification before performing
any property transfer which affects the location of the compliance boundary.
7>'Nothing Compares7—,
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

Ms. Elizabeth B. Fussell
January 30, 2017
Page 2 of 2
➢ Condition V1.7. — This condition requires continuous permit coverage until the facility is
properly closed.
➢ Condition VIX —This condition allows permit revocation or modification in certain situations.
➢ Condition VI.9. — This condition prohibits facility expansion if certain conditions prevail.
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 David Goodrich at (919)
807-6352 or'david.goodrichgncdenr.gov.
Sincerely,
-jtS. Jay Zimmerman, P.G., Director
Division of Water Resources
cc: Pender County Health Department (Electronic Copy)
Wilmington Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Digital Permit Archive (Electronic Copy)
Central Files

[at]_:II_M0..9W.1 *T0 @r,k/_1
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
Elizabeth B. Fussell
Pender County
FOR THE
continued operation of a 480 gallon per day (GPD) single-family residence wastewater treatment and
irrigation facility consisting o£
a 1,500 gallon precast concrete baffled septic tank with an effluent filter; a 1,700 gallon precast concrete
baffled recirculation tank with a 10 gallon per minute (GPM) recirculation pump, audible/visual high water
alarms, and a recirculating splitter valve; an Advantex ® AX20 textile -based filtration pod with a filter
surface area of 20 square feet (ft); a tablet chlorinator; a 4,900 gallon storage tank providing five days of
effective storage time with a 10 GPM irrigation pump, and a rainfall sensor; a 0.13 acre drip irrigation area;
and all associated piping, valves, controls, and appurtenances
to serve the single-family residence at 557 Belt Rd., Hampstead, NC 28443, with no discharge of wastes to
surface waters, pursuant to the application received January 23, 2017, 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 December 31, 2021, shall void Permit No.
WQ0033896 issued September 18, 2009, and shall be subject to the following specified conditions and
limitations:
I. SCHEDULES
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.0 105, 02T .0 109, 02T.01 15(c)]
2. 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. [I5A NCAC 02T .06071
WQ0033896 Version 2.0 Shell Version 151201 Page i of 6

U. PERFORMANCE STANDARDS
I . 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 .0100]
3. Application rates, whether hydraulic, nutrient or other pollutant, shall not exceed those specified in the
following table:
TABLE 1— APPLICATION LIMITATIONS
Field
Parameter
Hourly Rate
Yearly Max
Units
1
01284 — Non -Discharge Application Rate
0.12
49.61
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
Dominant
Acreage
Soil Series
1
Elizabeth B. Fussell
Pender
34.4570230
-77.5557320
0.13
Ra—Rains fine
sandy loam
[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 II1.5. of this permit. [I 5A 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.01,06, [ 15A NCAC 02L
.0107(i)]
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 A 107(c)]
WQ0033896 Version 2.0 Shell Version 151201 Page 2 of 6

10. The facilities permitted herein shall be constructed according to the following setbacks:
a. The setbacks for irrigation sites permitted under 15A NCAC 02T .0600 shall be as follows (all
distances in feet):
i. Any habitable residence or place of public assembly under separate ownership: 100
ii. Any habitable residence or place of public assembly owned by the Permittee:
is
iii. Any private or public water supply source:
100
iv. Surface waters:
100
v. Groundwater lowering ditches:
100
vi. Surface water diversions:
25
vii. Any well with exception of monitoring wells:
100
viii. Any property line:
501
ix. Top of slope of embankments or cuts of two feet or more in vertical height:
15
x. Any water line from a disposal system:
10
xi. Subsurface groundwater lowering drainage systems:
100
xii. Any swimming pool:
100
xiii. Public right of way:
50
xiv. Nitrification field:
20
xv. Any building foundation or basement:
15
Per a setback waiver recorded in the Pender County Register of Deeds, setbacks from the
wetted area to any property line has been reduced for the following:
[15A NCAC 02T .0606(a)]
b. The setbacks for storage and treatment units permitted under 15A NCAC 02T .0600 shall be as
follows (all distances in feet):
i. Any habitable residence or place of public assembly under separate ownership:
ii. Any private or public water supply source:
iii. Surface waters:
iv. Any well with exception of monitoring wells:
v. Any property line:
100
100
50
100
501
Per a setback waiver recorded in the Pender County Register of Deeds, setbacks from the
storage and treatment units to any property line has been reduced for the following:
PIN
PIN
Deed Book / Page
Setback
Easement
3709/0123
4236-50-1773-0000
3709/0123
39 feet
11 feet
[15A NCAC 02T .0606(a)]
b. The setbacks for storage and treatment units permitted under 15A NCAC 02T .0600 shall be as
follows (all distances in feet):
i. Any habitable residence or place of public assembly under separate ownership:
ii. Any private or public water supply source:
iii. Surface waters:
iv. Any well with exception of monitoring wells:
v. Any property line:
100
100
50
100
501
Per a setback waiver recorded in the Pender County Register of Deeds, setbacks from the
storage and treatment units to any property line has been reduced for the following:
PIN
Deed Book / Page
Setback
Easement
4236-50-1773-0000
3709/0123
10 feet
40 feet
f 15A NCAC 02T .0606(b)]
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)]
WQ0033896 Version 2.0 Shell Version 151201 Page 3 of 6

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]
3. 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(0)]
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(0)]
6. Only effluent from the single-family residence at 557 Belt Rd., Hampstead, NC 28443 shall be irrigated
on the sites listed in Condition 11.4. [G.S. 143-215.1]
7. 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(1)]
9. The residuals generated from the wastewater treatment facilities shall be disposed or utilized in
accordance with 15A NCAC 02T .1100. [15A NCAC 02T .1100].
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. 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 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 drip lines,
that the system is free of leaks, that the vegetative growth allows a proper drip 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)]
WQ0033896 Version 2.0 Shell Version 151201 Page 4 of 6

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 A 108(c)]
2. Noncompliance Notification:
The Permittee shall report by telephone to the Wilmington Regional Office, telephone number (910)
796-7215, 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:
a. 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.
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. [15A NCAC 02T .0105(l)]
I. 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 Permittee 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. [15ANCAC 02T .0110]
WQ0033896 Version 2.0 Shell Version 151201 Page 5 of 6

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.0 105(n).
[G. S. 14.-215.11
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 NCG010000; any requirements pertaining to wetlands under 15A NCAC 0213
.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)]
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
.0105(j)]
8. 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.01 10. [ 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 A 120(b). [ 15A
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 30' day of January 2017
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
7-S. Jay Zimmerman, P.G., Director
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number WQ0033896
WQ0033896 Version 2.0 Shell Version 151201 Page 6 of 6

State of North Carolina
I:Bepartrneut of Environment and Natural Resources
Division of Water Resources
i5A NCAC UST .D6{FD —SINGLE-Frf RESIDENCE WASTEWATER IRRIGATION SYSTEMS
is OPERATION AND MAINTENANCE AGREEMENT
-- ,.
�Iviso*n of Water I<esources FORM: SkWWIS O&M 08-13
Permit No. "t 0 0 3 3S i (o
County: �e v� d -6 v_
Property owner(s} as appearing on the recorded deed: C l i -Z. �-e- k us 5 e i
Mailingaddress: 55-'7 dad VV
Facility address: -,) aVvi (L
Irrigation Method: ❑ SPRAY �Z DRIP
�I'f�ff�Ct
2017
1 / We agree to operate and maintain the single-family residence wastewater treatment and irrigation system as follows:
1. The Permittee 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 pu€raped out as needed.
b. The septic tank effluent filter shall be checked and cleaned annually.
c. Accessible sand filter surfaces shall be raked and leveled every six months and any vegetative growth shall be
removed manually.
d. U 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 lainp(s) and quartz sleeve(s) shall be
cleaned or replaced as needed to ensure proper disinfection.
e. All pump and alarm systems shall be inspected monthly,
f. The irrigation syste€n 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 he cause for the Division to revoke the perinit pursuant to 15A NCAC 02T
.0105(e)(3).
3. The Per€nittee's failure to properly operate this systean is subject to a penalty tip to $25,000 per day.
4. Failure to meet the permit conditions or violation of the State's surface water or groundwater regulations may void
the permit,
All owners appearing on the legally recorded propgr1l deed shall sign this Operation & Maintenance Agreement
I / We understand the above requirements and agree to these terms as part of the issued permit.
Owner Signature: UJB f'�(✓ ? Date
0w17er S ignat€ re:
Bate:
FORM: SFRWWIS O&M 08-13, Page l of 1

State of North Carolina
RECEIVED 1 DENR D%ortment. of Environment and Natural Resources
3
Aquife r,n 5ecttoR Division of Water Quality
JUL a i 2009
i
SETBACK WAIVER FORM
(THIS FORM MAYBE PHOTOCOPIED FOR USE RS AN ORIGINAL)
5
The Division of Water -Quality will not consider this attachment form to be complete unless all the
instructions are followed. Failure to follow the instructions or to submit all of the required items
a
will lead to additional processing and review time for the application.
For more information orf an electronic version of this form, visit our web site at:
a Min"
'
http: //h2o. enr. crate. nc. u,r/laulapplications.html
= �•
INSTRUCTIONS TO THF APPLICANT:
A. Attachment Form -
y
Do notsubmit � attachment form for review without a corresponding Land Application Unit
application orm.
✓ Any changes to this attachment form will result in the application package being returned.
r�
� Any other setbacks required by ISA NCAC2T .0506 2nd.0606 other than those referenced below, cannot
" a
be waived through execution of this form.
N d ®oN
+� A copy of the completed and appropriately executed form must be provided to the property owner,
1p o
�m
m
AGREEMENT TO WAIVE THE SETBACK REQUIRED BY
0
I5A NCAC ZT .0506(a), .0506(b) and .DW(a)
The undersigned property owner(s) hereby permits: i
Applicant's name: Elizabeth Fussell 1/
Complete mailing address of applicant: PO Box 2507
City: Surf City State: NC 28445
Telephone number: ( 910) 328-4141 Facsimile number:(_)
hereinafter referred to as the Permittee, to (check all that apply):
® Irrigate wastewater within 3-9 feet of the property line,
❑ Irrigate wastewater within feet of the identified residence,
51 Construct wastewater treatment emits within 10 feet of the property line,
as shown on the attached map and located at the following:
Location address ofpropetty: Belt Road (Pin No: 4236-50-1773-0000)
City; Holly Ridge State: NC zip: 28445
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 understated this Agreement and do hereby grant permission to the permittee to
irrigated wastewater or construct wastewater treatment units as specified herein. 1 further avrce that
upon issuance of a permit by the Division for the wastewater irrigation system I will record this
waiver forth with the appropriate Register of Deeds and provide the permittee with documentation of
Stich -
Property owner(s) name(s).-
ttch_Propertyowner(s)narne(s): Elizabeth B. Fussell
Signature: ` -Date:
Signature: za ' _ , _Date: / /- —D `�

111111111111111111!111111111111111111 F U Te C�i?7 Ar1-23-2009
ev0 21.0ec
Pender County, NC Register of Deeds page 2 of 2
STATE OF ,,,COUNTY OF
A NOTARY PUBLIC IN AND FOR `.C`HE
A FORESAID COUNTY AND STATE DO HEREBY CERTIFY THAT �
PERSONALLY APPEA D BEFORE ME
THIS DAY AND BEING DULY SWORN DO HEREBY ACKNOWLEDGE THE DUE EXECUTION OF
THE FOREGOING INSTRUMENT FOR THE PURPOSES NTEREIN STATED,
THIS DAY OF Q� UQ r ll lN` dac?-
a' (SEAT)
(NOTARY SIGNATURE)
(SEAL)
My COMMISSION EXPIRES:
i e}pTAl�y � r
a'U L�.C'4F