WQ0040626_Final Permit_20190613

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
ANDREW T. AND HOLLY G. MILLER
5603 MISTY HILL CIRCLE
CLEMMONS, NORTH CAROLINA 27012
Dear Mr. and Mrs. Miller:
NORTH CAROLINA
Environmental Quality
June 13, 2019
Subject: Permit No. WQ0040626
1725 Stonefield Ln. SFR
Single -Family Residence
Wastewater Irrigation System
Forsyth County
In accordance with your permit application request received February 6, 2019, and subsequent
additional information received April 30, 2019 and June 3, 2019, we are forwarding herewith Permit No.
WQ0040626 dated June 13, 2019, to Andrew T. and Holly G. Miller 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 through March 31, 2025, and shall be
subject to the conditions and limitations therein. The Permittee shall submit a renewal application no
later than October 2, 2024.
Please pay attention to the operation and maintenance requirements listed in Section III. Failure to
establish an adequate system for collecting and maintaining the required operational information shall result
in future compliance problems.
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. Otherwise, this permit shall be final and binding.
One set of approved plans and specifications is being forwarded to you. If you need additional
information concerning this permit, please contact Erick Saunders at [phone] or
erickson. saundersAncdenraov.
Sincerely,
Dda Culpepper, Director
ivision of Water Resources
cc: Forsyth County Health Department (Electronic Copy)
Winston-Salem Regional Office, Water Quality Regional Operations Section (Electronic Copy)
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617
NORTH CARW k Q
mrat 919.707.9000

Mr. Andrew T. Miller and Mrs. Holly G. Miller
June 13, 2019
Page 2 of 2
John R. Harmon, PE (Electronic Copy)
Laserfiche File (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
Andrew T. and Holly G. Miller
Forsyth County
FOR THE
construction and operation of a 480 gallon per day (GPD) single-family residence wastewater treatment
and irrigation facility consisting of.
a 1,000 gallon septic tank with an effluent filter; a 1,250 gallon recirculation tank with a 20 gallon per
minute (GPM) recirculation pump dosing an Advantex AX-20 filter treatment pod; an ultraviolet (UV)
disinfection unit; a 3,500 gallon storage/dosing tank with high-water alarms, and a 16 GPM field dosing
pump; a rain sensor; a 0.35 acre spray area with eight spray heads; and all associated piping, valves,
controls, and appurtenances
to serve the single-family residence at 1725 Stonefield Ln., Clemmons, NC 27012, with no discharge of
wastes to surface waters, pursuant to the application received February 6, 2019, subsequent additional
information received April 30, 2019 and June 3, 2019, and in conformity with the Division -approved plans
and specifications considered a part of this permit.
This permit shall be effective from the date of issuance through March 31, 2025, and shall be subject to the
following conditions and limitations:
I. SCHEDULES
Upon completion of construction and prior to operation of this permitted facility, the Permittee shall
submit an engineering certification from a North Carolina licensed Professional Engineer certifying
that the permitted facility has been constructed in accordance with G.S. 143-215.1, Administrative
Code Title 15A Subchapter 02T, this permit, and the Division -approved plans and specifications. For
phased and partially certified facilities, the Permittee shall retain the responsibility to track further
construction approved under this permit, and shall provide a final engineering certification upon project
completion. Mail the Engineering Certification to the Division of Water Resources, Non -Discharge
Branch, 1617 Mail Service Center, Raleigh, NC 27699-1617, or Non-Discliggge.Reportsodncdenr.gov.
[15A NCAC 02T .0I 16(a)]
2. The Permittee shall notify the Winston-Salem Regional Office, telephone number [phone], at
least two business days in advance of initial operation of the constructed facilities so that the Division
can conduct a startup inspection. [15A NCAC 02T .0108(b)(1)(B)]
WQ0040626 Version 1.0 Shell Version 181105 Page 1 of 8

3. The Permittee shall request renewal of this permit on Division -approved forms no later than October
2, 2024. [15A NCAC 02T .0105(b), 02T .0109]
4. If a public or community sewage system is or becomes available, the Permittee shall connect to this
system, and shall request rescission of the single-family residence wastewater treatment and irrigation
facilities permitted herein. [ 15A NCAC 02T .0607]
H. PERFORMANCE STANDARDS
The Permittee shall maintain and operate the subject non -discharge facilities 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 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)(A)]
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 02T .0108(b)(1)(A)]
3. The Permittee shall apply treated wastewater effluent at or below the following rates:
TABLE 1— APPLICATION LIMITATIONS
Field
Parameter
Hourly Rate
Yearly Max
Units
1
01284 — Non -Discharge Application Rate
0.3
17.27
inches
[15A NCAC 02T .06050)]
4. The Permittee shall only apply treated wastewater effluent to the following:
TABLE 2 — IRRIGATION AREA INFORMATION
Field
Owner
County
Latitude
Longitude
Net
Dominant
Acrea a
Soil Series
I
Andrew T. and Holly G.
Miller
Forsyth
36.0594550
-80.4500800
0.35
Rasalo/Siloam
[15A NCAC 02T .0 1 08(b)(1)(A)]
5. The attached Operation and Maintenance Agreement shall be a condition of this permit.
Noncompliance with the terms of the Operation and Maintenance Agreement shall subject the Permittee
to all sanctions under G. S. 143-215.6A, G.S. 143-215.613, and G.S. 143-215.6C for violation of or
failure to act in accordance with the terms and conditions of this permit. [ 15A NCAC 02T .0604(h)]
6. The Permittee shall connect the irrigation system to a rain or moisture sensor designed to prevent
irrigation during precipitation events or wet conditions. [15A NCAC 02T .0605(o)]
7. The compliance boundary is the property boundary. Any exceedance of groundwater standards at or
beyond the compliance boundary shall require corrective action. Division -approved relocation of the
compliance boundary shall be noted in Condition II.4. Multiple contiguous properties under common
ownership and permitted for use as a disposal system shall be treated as a single property with regard
to determination of a compliance boundary. [ 15A NCAC 02L .0106(d)(2), 02L .0107(i), 02T .0105(h),
G.S. 143-215.1(i), G.S. 143-215.1(k)]
8. The review boundary is midway between the compliance boundary and the effluent disposal area. Any
exceedance of groundwater standards at or beyond the review boundary shall require preventative
action. [ 15A NCAC 02L .0106(d)(1), 02L .0108]
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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 (i.e., parcel subdivision). [ 15A NCAC
02L .0107(c)]
10. The facilities herein were permitted per the following setbacks:
a. The irrigation sites were originally permitted June 13, 2019. The setbacks for spray irrigation sites
originally permitted or modified on or after September 1, 2018 are as follows (all distances in feet):
i. Each habitable residence or place of assembly under separate ownership:
400'
ii. Each habitable residence or place of assembly owned by the Permittee:
2002
iii. Each private or public water supply source:
100
iv. Surface waters:
100
v. Groundwater lowering ditches:
100
vi. Surface water diversions:
25
vii. Each well with exception of monitoring wells:
100
viii. Each property line:
150 3
ix. Top of slope of embankments or cuts of two feet or more in vertical height:
15
x. Each water line:
10
xi. Subsurface groundwater lowering drainage systems:
100
xii. Public right of way:
50
xiii. Nitrification field:
20
xiv. Each building foundation or basement:
15
1 Habitable residences or places of assembly under separate ownership constructed after the
facilities herein were originally permitted or subsequently modified are exempt from this
setback.
2 Per a setback waiver recorded in the Forsyth County Register of Deeds, reduced setbacks from
the wetted area to any habitable residence or place of assembly owned by the Permittee are as
follows:
Parcel No.
Deed Book / Page
Setback
Easement
5874-13-3677
3452 / 4022
85 feet
115 feet
3 Setbacks to property lines are not applicable when the Permittee, or the entity from which the
Permittee is leasing, owns both parcels separated by the property line.
[15A NCAC 02T .0606(a), 02T .0606(c), 02T .0606(d), 02T .0606(e)]
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b. The storage and treatment units were originally permitted June 13, 2019. The setbacks for storage
and treatment units originally permitted or modified on or after September 1, 2018 are as follows
(all distances in feet):
i. Each habitable residence or place of assembly under separate ownership: 100,
ii. Each private or public water supply source: 100
iii. Surface waters: 50
iv. Each well with exception of monitoring wells: 100
v. Each property line: 50 2
1 Habitable residences or places of assembly under separate ownership constructed after the
facilities herein were originally permitted or subsequently modified are exempt from this
setback.
2 Setbacks to property lines are not applicable when the Permittee, or the entity from which the
Permittee is leasing, owns both parcels separated by the property line.
[15A NCAC 02T .0606(b), 02T .0606(d), 02T .0606(e)]
III. OPERATION AND MAINTENANCE REQUIREMENTS
1. The Permittee shall operate and maintain the subject facilities as anon -discharge system. [ 15A NCAC
02T .0600]
2. Upon the Water Pollution Control System Operators Certification Commission's (WPCSOCC)
classification of the subject non -discharge facilities, the Permittee shall designate and employ a certified
operator in responsible charge (ORC), and one or more certified operators as back-up ORCs. The ORC
or their back-up shall operate and visit the facilities as required by the WPCSOCC. [15A NCAC 02T
.0117]
3. The Permittee shall maintain vegetative cover on the irrigation sites, such that crop health is optimal,
allows even effluent distribution, and allows inspection of the irrigation system. [15A NCAC 02T
.0608(a)]
4. The Permittee shall take measures to prevent effluent ponding in or runoff from the irrigation sites
listed in Condition IL4. [15A NCAC 02T .0608(b)]
5. The Permittee shall not irrigate treated effluent during inclement weather, or when the soil is in a
condition that will cause ponding or runoff. [15A NCAC 02T .0605(o)]
6. The Permittee shall only irrigate treated effluent from the single-family residence at 1725 Stonefield
Ln., Clemmons, NC 27012 on the sites listed in Condition IIA. [15A NCAC 02T .0601]
7. The Permittee shall not allow vehicles or heavy machinery on the irrigation area, except during
equipment installation or maintenance activities. [15A NCAC 02T .0608(d)]
8. The Permittee shall prohibit public access to the wastewater treatment and irrigation facilities through
lockable treatment units, and fencing around the irrigation sites. [15A NCAC 02T .0605(i)]
9. The Permittee shall dispose or utilize generated residuals in a Division -approved manner. [ 15A NCAC
02T .1100].
10. The Permittee shall not divert or bypass untreated or partially treated wastewater from the subject
facilities. [15A NCAC 02T .0605(f)]
11. Pump tanks shall have audible and visual alarms external to any structure. [ 15A NCAC 02T .0605(n)]
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12. The Permittee shall line any excavation into bedrock with a 10 millimeter synthetic liner. [15A NCAC
02T .0605(d)]
13. Metering equipment shall be tested and calibrated annually. [15A NCAC 02T .0608(c)]
14. The Permittee is responsible for the operation and maintenance of the wastewater treatment and
irrigation system including the following:
a. Inspect the septic tank annually, and pump out solids as needed. Inspect and clean the septic tank
effluent filter annually.
b. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as
needed.
c. Inspect all storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all
pump/storage tanks when pumping the septic tank solids out.
d. Inspect the spray irrigation system monthly to verify: proper operation of the spray heads; that there
are no leaks; that vegetative growth does not obstruct the spray heads; that the irrigated wastewater
is not ponding in or running off the designated irrigation area; and that there are no objectionable
odors.
[15A NCAC 02T .0608]
IV. MONITORING AND REPORTING REQUIREMENTS
1. The Permittee shall conduct and report any Division required monitoring necessary to evaluate this
facility's impact on groundwater and surface water. [15A NCAC 02T .0108(c)]
2. Noncompliance Notification:
The Permittee shall report to the Winston-Salem Regional Office, telephone number [phone],
within 24 hours of first knowledge of the following:
a. Any process unit failure (e.g., mechanical, electrical, etc.) rendering the facility incapable of
adequate wastewater treatment.
b. Any facility failure resulting in a discharge to 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.
Emergencies requiring reporting outside normal business hours shall call the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone]. All
noncompliance notifications shall file a written report to the Winston-Salem Regional Office within
five days of first knowledge of the occurrence, and this report shall outline the actions proposed or
taken to ensure the problem does not recur. [15A NCAC 02T .0108(b)(1)(A)]
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V.
1. The Permittee shall perform inspections and maintenance to ensure proper operation of the wastewater
treatment and irrigation facilities. [15A NCAC 02T .0608(f)]
2. The Permittee shall inspect the wastewater treatment and irrigation facilities to prevent malfunctions,
facility deterioration, and operator errors that may result in discharges of wastes to the environment,
threats to human health, or public nuisances. The Permittee shall maintain an inspection log that
includes the date and time of inspection, observations made, and 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
.0608(e), 02T .0608(f)]
3. Division authorized representatives may, upon presentation of credentials, enter and inspect any
property, premises, or place related to the wastewater treatment and irrigation facilities permitted herein
at any reasonable time for determining compliance with this permit. Division authorized
representatives may inspect or copy records 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 a
Division enforcement action. [G.S. 143-215.6A, 143-215.6B, 143-215.6C]
2. This permit is effective only with respect to the nature and volume of wastes described in the permit
application, and Division -approved plans and specifications. [G.S. 143-215.1(d)]
3. Unless specifically requested and approved in this permit, there are no variances to administrative codes
or general statutes governing the construction or operation of the facilities permitted herein. [15A
NCAC 02T .0105(n)]
4. The issuance of this permit does not exempt the Permittee from complying with all statutes, rules,
regulations, or ordinances that other jurisdictional government agencies (e.g., local, state, and federal)
may require. [15A NCAC 02T .0105(c)(6)]
5. If the permitted facilities change ownership, or the Permittee changes their name, the Permittee shall
submit a permit modification request on Division -approved forms. The Permittee shall comply with
all terms and conditions of this permit until the permit is transferred to the successor -owner. [G.S. 143-
215.1(0)]
6. The Permittee shall retain a set of Division -approved plans and specifications for the life of the facilities
permitted herein. [15A NCAC 02T .0105(o)]
7. The Permittee shall maintain this permit until the proper closure of all facilities permitted herein, or
until the facilities permitted herein are permitted by another authority. [15A NCAC 02T .01050)]
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8. This permit is subject to revocation or modification upon 60-day notice from the Division Director, in
whole or part for:
a. violation of any terms or conditions of this permit or Administrative Code Title 15A Subchapter
02T;
b. obtaining a permit by misrepresentation or failure to disclose all relevant facts;
c. the Permittee's refusal to allow authorized Department employees upon presentation of credentials:
i. to enter the Permittee's premises where a system is located or where any records are required
to be kept;
ii. to have access to any permit required documents and records;
iii. to inspect any monitoring equipment or method as required in this permit; or
iv. to sample any pollutants;
d. the Permittee's failure to pay the annual fee for administering and compliance monitoring; or
e. a Division determination that the conditions of this permit are in conflict with North Carolina
Administrative Code or General Statutes.
[15A NCAC 02T .0110]
9. Unless the Division Director grants a variance, expansion of the facilities permitted herein shall not
occur if any of the following apply:
a. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has been convicted of
environmental crimes under G.S. 143-215.613, or under Federal law that would otherwise be
prosecuted under G.S. 143-215.6B, and all appeals of this conviction have been abandoned or
exhausted.
b. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has previously abandoned
a wastewater treatment facility without properly closing the facility.
c. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has not paid a civil
penalty, and all appeals of this penalty have been abandoned or exhausted.
d. The Permittee or any parent, subsidiary, or other affiliate of the Permittee is currently not compliant
with any compliance schedule in a permit, settlement agreement, or order.
e. The Permittee or any parent, subsidiary, or other affiliate of the Permittee has not paid an annual
fee.
[15A NCAC 02T .0120(b), 02T .0120(d)]
10. This permit shall not be renewed if the Permittee or any affiliation has not paid the required annual fee.
[ 15A NCAC 02T .0120(c)]
Permit issued this the 131 day of June 2019
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
tu
mda Culpepper, Director
, Division of Water Resources
By Authority of the Environmental ManagJnt Commission
Permit Number WQ0040626
WQ0040626 Version 1.0 Shell Version 181105 Page 7 of 8

Permit No. WQ0040626 Single -Family Residence Wastewater Irrigation System
Andrew T. and Holly G. Miller June 13, 2019
1725 Stonefield Ln. SFR Forsyth County
ENGINEERING CERTIFICATION
❑ Partial ❑ Final
I,.— _ , as a duly licensed North Carolina Professional
Engineer, having ❑ periodically / ❑ fully observed the construction of the permitted facilities, do hereby
state to the best of my abilities that the facility was constructed in compliance with G.S. 143-215.1,
Administrative Code Title 15A Subchapter 02T, this permit, and the Division -approved plans and
specifications.
Documentation of any variation to this permit, and the Division -approved plans and specifications, is in the
attached as -built drawings.
Description of variations:
Professional Engineer's Name
Firm Name Firm No.
Address
City State j Zip Code
Telephone Email Seal, Signature, and Date
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
DOCUMENTATION, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
NON -DISCHARGE BRANCH
By U.S. Postal Service By Courier/Special Delive
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
WQ0040626 Version 1.0 Shell Version 181105
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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
DWR
ISA NC.AC 02T.0600 —SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEMS
OPERATION AND MAINTENANCE AGREEMENT
DMsioe of Water Resources
FORM: SFRWWIS O&M 08-13
Permit \o. �O Zt;.� CCounty:��7� 1(�r
`FG"�` o%%wr(s) as appearing on the recordPr
ed deed: £ r t �-�- �` t G
m1i.-ig a►i`3. iL7 3 i`�{ t. "fILI. 6 L [.Li; _f�_I .�+ MO ►� 5: h1 e
Fwl, i, address-, l Z 7-i�7 STo Lei~ t laLo LSE-- ('_LE t,nNk , r%5. t-LC ; 270 r Z
lrir ion L SPRAY ❑ DRIP
I..' We _.__ to o-crate and maintain the single-family residence wastewater treatment and irrigation system as follows:
1. Tire P..mit ` is responsible for the operation and maintenance of the entire wastewater treatment and irrigation
s�--=-,n i:k:ttding_ but not limited to, the following items:
a The s. c L°'tk s�%all be checked annually and pumped out as needed.
b. The s��c tmtk effluent filter shall be checked and cleaned annually.
c Access-fzle swhl filtersurfaces shall be raked and leveled every six months and any vegetative growth shall be
r=o%..: mwjally.
d. ❑ Tire table:. chlorinator shall be checked weekly. Wastewater grade tablets (calcium hypochlorite) shall be
added a; rt---°ed to provide proper chlorination (pool chlorine tablets shall not be used), OR
The ulamiolet disinfection unit shall be checked weekly. The lamp(s) and quartz sleeves) shall be
dwr. or replac d as needed to ensure proper disinfection.
e. All pt>mp and alarm systems shall be inspected monthly.
The i riga:rion system► shall be inspected monthly to ensure that the system is free of leaks, that all irrigation
e:rt'SIL"fa e:ri is operating as designed, that vegetative growth does not interfere with the system inspection or
o�on, that the sot] is assimilating the disposed treated wastewater with no visible runoff or ponding, and
that Do objectionable odors are being generated.
3 Fafl:rr m pay the annual fee shall be cause for the Division to revoke the permit pursuant to 15A NCAC 02T
.0105(e)(3).
3. The Permittee's failure to properly operate this system is subject to a penalty up to S25,000 per day.
4. F29uxe to me= the permit conditions or violation of the State's surface water or groundwater regulations may void
the nermiL
All owners appearing on the lea Ilv recorded property deed shall sign this Operation & Maintenance Agreement
I I VVe rid the above requirements and
agree to these terms as part of the issued permit.
oat Sig4ttIre: ! Date: _4
OwzIC7 Sign2111M Date: 'i r
FOR.t4: SFRWV61S O&M 08-13 Page 1 of 1
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NI111111��8�IIIII�I�NII II��' �
2019011268 00059
j FORSYTH CO. NC FEE S26.06
ISIE SEN7EU RAEf.U/DED
04-01-201911:56:15 AM
LYNNEJOHNSON
NEGMIFU M DEEDS
IM OUVIA DOYLC
ASST
BK: RE 3452
PG: 4022-4023
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE WASTWATER SYSTEM WAIVER
AGREEMENT TO WAIVE SETBACKS AS REQUIRED BY
A� 15A NCAC 02T.0506(a), .0506(b), .0606(a), .0706(a) AND .1006(a)
I, Wy,plZlr! �, Nt t I�Gi'L, certify that I am a deeded owner of the property located at:
Address:r t � 9 � a Parcel No.: 5 `Ps A,
City: Ci 1414% M a- 0 S State: I. Zip Code: 2 a 1 County: PW "
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.
❑ 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 property line.
understand the setback requirements set forth in 15A NCAC 02T. For the parcel identified
above, .I consent to a reduced setback from Igo 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
construction of wastewater treatment and storage units as near as feet from my residence. Signature:LAI,�o 1 f Date: - l
FORM: NDWSW 03-17 Page I of 2
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ApplicantlPermittee:
Address: 1: j 1r7 k ;'7 � t Parcel No.: 1 r
City:-C�e T�!`ti�t•i�% - - State: ZipCoderl ZCounty: rN
NORTH CAROLIINA, 446�M COUNTY
II, _, a Notary Public for County, North Carolina,
do hereby certify that �- i�ii personally appeared before me this day
and acknowledged the due execution of the foregoing instrument.
Witness my hand and official seal, this the —L day of
SEAL
PATRICIA KING WEST
NOTARY PUBUC
Fors)h County
NOM Carolina
Coed Expires January 24, 21P11
ti
Signature of Notary Public
My commission expires I K - L�' "
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 2of2
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