A23 138��rson County Health Departm�,�....�
`��ew� System Improvements Permit
Date: rZ . Permit Void Aftelr 3 Years /�
Owner. •---=�$�-s�_�'�✓p ,C�C�r��:���'ir��# �:�� �
,C�
Subdivision Name: _ � T �rs.a��t;�, j� �,'�
I:o.t Size: . t. � Typg of Dwelling: _
W.ater Supp y: Private: _�,.� Public:
Semi Private: If not Private Tax Map# ;_
Parcel # of Water Supply or Name of
Supplier# �
Bedrooms:�_ Garbage Disposal
Basement Basement Fixtures
INFORMATIO BY ''
S8Ilitaii8ll: � � o er or
REPAIR: EV�UATION:
Size of Septic Tank: OPi �allons ����
Nitrification Line: � �, � �,�,�, �'�,fT�
Depth of Stone: 12 inches
Max Denth of Trenches:
Lot #
G
❑�
�
�
.
�����^���.�.��c�,��.�i���������
Date Well Approved: Well should be 100 ft from any sewec systen
BY Sanitarian
Date Sewage System Approved:
BY Sanitarian
CERTIFICATE OF COMPLETION � �
Contractor.
------------------------- �:
b
Sewage System location, installadon. and protection must meet state and local �
reguladons. Septic tank should be pumped out every 3 to 5 years and shall be
maintained by owner in such manner as not to create a public health hazard. �;
Septic tank and ni�ification line must be inspected and approved by a member of �J `
the Person County Health Department before any portion of the installation is W;
covered and put into use. '
,
I.ocation of sewage disposal sewage system sketched on back. � N'�
� �
• (OVER)
!
�
(� - /Z
1 �
,
� 1�
��.,
�m5s��
��-aa
��'�"��
�.o Ck
C�Q ' ,
��� �
��-�-�- ��
►
arl / ('C�"' " , �
/� v
i5"
��o�
�
., . . . GpUN7Y (�
�ti
�� �'y
.
* *
* *
� «
.^'
PERSON COUNTY ���N���`0
PERSON COUNTY HEALTH DEPARTMENT
ENVII20NMENTAL H�ALTH PROGRAM
20.B Court Street
Roxboro, North Cazolina 27573 :
(336) 597-1790
February 7, 2001
Steve Bamhardt
417 Stonewyck Drive
Burlington, NC 27215
Re: Application for improvement perrnit for Wastewater system for property at Heritage
Harbor Subdivision Lot D .
Person County Health Department File: Tax Map #A23, Parcel #138
Dear Mr. Bamhardt:
The Person County Health Department, Environmental Health Division on July 28, 2000,-and
September 20, 2000 evaluated the above-referenced property at the site designated on the
plat/site plan that accompanied your improvement permit application. According to your
application the site is to serve a three-bedroom residence with a design wastewater flow of
360 to 480 gallons per day. The evaluation was done in accordance with the laws and rules
governing wastewater systems in North Carolina General Statute 130A-333 and related
statutes and Title 15A, Subchapter 18A, of North Carolina Administrative Code, Rule .1900
and related rules.
Based on the criteria set out in Title 15A, Subchapter 18A, of the North Carolina
Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is
UNSUITABLE for a ground absorption sewage system. Therefore, your request for an
improvement permit is DENIED. The site is unsuitable based on the foliowing: �
1. . Soil depths to saprolite unsuitable (Rule .1943).
2. Unsuitable soil characteristics (Morphology) (Rule.1941)
3. Soil wetness conditions indicated by chroma colorization (Rule .1942)
. 4. Insufficient Available Space (Rule.1945)
These severe soil or site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, in surface waters, directly into ground
water or inside your structure.
The site evaluation included consideration of possible site modifications, and modified,
innovative or altemative systems. However, the Health Department�has determined that
none of the above options will overcome the severe conditions on this site. A possible option
might be a system designed to dispose of sewage to another area of suitable soil or off-site�to
additional property. �
For the reasons set out above, the property is currently classified UNSUITABLE, and an
improvement permit shall not be issued for this site in accordance with Rule .1948.
However, the site classified as UNSUITABLE may be classified as PROVISIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule
.1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish
to try to develop a plan under which your site could be reclassified as PROVISIONALLY
SUITABLE.
You have a right to an informal review of this decision. You may request an informal review
by the soil scientist or environmental health supervisor at the local health department. You
may also request an informal review by the N.C. Department of Environment and Natural
Resources regional soil specialist. A request for an informal review must be made in writing
to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you
must file a petition from a contested case hearing with the Office of Administrative Hearings,
6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write
the Office of Administrative Hearings or call the office at (919) 733-0926. The petition for a
contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter 150B.
N.C. General Statue 130A-335 (g) provides that your hearing would be held in the county
where your property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form with the
Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER.
Meeting the 30-day deadline is critical to your right to a formal appeal. Beginning a formal
appeal within 30 days will not interfere with any informal review that you might request. Do
not wait for the outcome of any informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings,
you are required by law (N.C. General Statute 150B-23) to send a copy of your petition to the
North Carolina Department of Environment and Natural Resources. Send the copy to: Office
of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail
Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to your
local health department. Sending a copy of your petition to the local health department will
NOT satisfy the legal requirement in N.C. General Statute 1506-23 that you send a copy to
the Office of General Counsel, NCDENR.
You may call or write the Person County Environmental Health Department if you need any
additional information or assistance.
Since�el�r, �
� `+'� ,��� � '
Janet O. Clayton, R.S.
Environmental Health Supervisor
Environmental Health Division
Person County Health Department
� • �, .
�
,.. �
<�' � k: �.� �
: �� �...>. � �������i-.�
��n�n��nan��n�.��.� �c��.���
Sertemher 17, 2002
Mr. Steve Barnhardt
417 Stonewyck Ln.
Burlington, NC 27215
x '
nea]t�y;`e�yironme�t';` ,
Re: Application for improvement permit for Wastewater system for property at
Heritage Harbor Subdivision, Lots A, C, and D- Tax Map# A23 Parcel#'s
135, 137, and 138
De�r Mr.Barnhardt:
The Person County Health Denartment, Environmental Health Section evaluated the above-referenced property at
the site designated on the pladsite plan that accompanied your improvement permit application, on September 12,
2002. According ro your application the site is to serve as an off-site area for the installation of wastewater systems
designed to serve three, three-bedroom residences with a design wastewater flow of 360 gallons per day each. The
evaluati�n was done in accordance with the 11ws and rules governing wastewa[er systems in North Carolina General
Statute 130A-333 and related statutes and Tide 15A, Subchapter 18A, of North Carolina Administrative Code, Rule
.1900 and related rules.
Based on [he criteria set out in Tide I SA, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940
through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system.
Therefore, your request for an improvement permit is DENIED. The site is unsuitable based on the fc�llowing:
I. Soil Depths to saprolite and rock unsuitable (Rule .1943).
2. Inadequate Available Space (Rule.1945)
3. Unsuitable Depth to Soil We[ness Condition (Rule .1942)
4. Soil Mo��hology (unsuitable clay minerology) �Rule .1941)
These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated
sewage to the ground surface, surface waters, directly to ground water, or inside your structure.
The site evaluation included consideration of possihle site modifications, and modified, innovative or allernative
systems. However, the Health Department has determined that none of the �bove options will overcome the severe
conditions an this site. A possible option might he 1 system designed to dispose of sewage to another area of
suitable soil or off-site to additional property.
F�r the reas�ns set out above, the property is currently classified UNSUITABLE, and an improvement permit shall
not be issued for this site in accordlnce with Rule .1948(c).
However, the site classified as UNSUITABLE may be classified as PROVISIONAI.LY SUITABL� if written
documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may
hire a consult�nt to assist you if you wish to try to develop a Plan under which your site could be reclassified as
PROVISIONALLY SUITABLE.
phone 336.597.1790
fax 336.597.7808
20-B Court Street, Roxboro, NC 27573
You have a right to an informal review of this decision. You may request an infarmal review by the soil scientist or
environmental health supervisor at the local health department. You may also request an informal review by the
N.C. Department of Environment and Natural Resources regional soil specialist. A request for an informal review
must be made in writing to the local health department.
You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition from a
contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714.
To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 733-
0926. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina
General Statutes 140A-24 and 150B-23 and all other applicable provisions of Chapter 150B. N.C. General Sta[ue
130A-335 (g) provides that your hearing would be held in the county where your property is located.
Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative
Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. Meeting the 30 day deadline is critical to
your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review
that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal.
If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by
law (N.C. General Statute I SOB-23) to send a copy of your petition to the North Carolina Department of
Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of
Environment.and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy
of the petition to your local health de�artment. Sending a copy of your petition to the local health department will
NOT satisfy the legal requirement in N.C. General Statute i50B-23 that you send a copy to the Offce of General
Counsel, NCDENR.
You may call or write the Person County Health Department, Environmental Health Section, if you need any
additional information or assistance.
Sincerely, �
� �.,
� � .
Michael E. Cash, R.S.
Environmental Health Program Specialist
Person County Health Department
Cc: Janet Clayton, Environmental Health Supervisor
File
' R
x< �'
�^{ ��4
�
�.
,�:; � •
a r�;❑.,,
.�;,.
Water Resources
ENYIRONMENTAI QUAIITY
PAT MCCRORY
Goverrlor
DONALD R. VAN DER VAART
Secretary
S. JAY ZIMMERMAN
Dircctor
S"I'EVEN M. AND RITA B. BARNHARDT
417 STONEWYCK DRIVE
BURLINGTON, NORTfI CAROLINA 2721 S
Dear Mr. and Mrs. Barnhardt:
December 14, 2016
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.
P(ease note the following permit conditions have been removed since the last permit issuance
dated November 9, 2007:
➢ Old Conditions I.S., I.6., and I.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.l l.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 II.4. — This condition includes information about the wastewater irrigation field.
State of North Carolina � Environmental Qunlity � Water Resowces � Watcr Quality Permitting � Non-Discharge Pe�tnitting
1617 Mail Scrvice Ccntcr � Ralei�h, North Cazolina 27699-1617
919 807 64G4
�"�"�A"" � >s=,
L.:
Mr.�Steven M. Barnhardt and Mrs. Rita Q. I3arnhardt
December 14, 2016
Page 2 of 2
➢ Condition II.7. — This condition establishes the compliance boundary at the property boundary
in accordance with 15A NCAC 02L .0107(i).
➢ Condition I1.8. — This condition establishes the review boundary midway between the
compliance boundary and the disposal area in accordance with 15A NCAC 02L .0108.
➢ Condition II.9. — 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 N.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 shal! 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 1 SA NCAC 02T .O 110.
➢ 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 sliall be in the form of a written petition, conforming to Chapter I SOB of the North
Carolina General Statutes, and filed with the Officc 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(�a,ncdenr.�ov.
Sincerely,
���
�.�,S. Jay Zimmerman, P.G., Director
o -Division of Water Resources
cc: Person County Health Department, Harold Kelly, Environmental Health Supervisor,
bkellX�a personcountv.net (Electronic Copy)
Raleigh Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Di�ital 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. ancl Rita B. Barnhardt
Person County
FOR THE
construction and operation of a 480 gallon per day (GPD) single-family residence wastewater treatment
and irrigation facility consisting of:
a 1,250 gallon baffled septic tank; two 210 square foot (ftZ) sand filters; a chlorine contact basin; a 1,578
gallon storage tank; a 2,440-gallon pump tank; approximately 485 linear feet (LF) of'/<-inch force main; a
0.23 acre spray irrigation area with fve 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
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 proiect is to be completed in phases and partiallvi certified, the Permittee shall retain
the responsibility to track further construction approved under the same permit, and shall vrovide a
final certificate of completion once the entire project has been comnleted. 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 (9l9) 791-4200, 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 .0108 (b)(2)]
WQ0022307 Version 3.0 Shell Version 151201 Page 1 of 7
3. 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 .Ol 15(c)]
4. lf 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
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 LIhTITATIONS
Field Parameter Hourly Rate Yearly Max Units
1 01284 — Non-Discharge Application Ratc 0.25 30.3 inches
[l SA NCAC 02T .0605(j)]
4. The subject facility has been approved to land apply wastewater effluent ori the following fields:
TABLE 2— IRRIGATION AREA IAIFORMATION
Field Owner County Latitude Longitude Net Acreage Dominant
Soil Series
1 Steven M. and Rita B. Person 36.518791 °-79.070390° 0.23 W� W►1kes Loam, 2-
Barnhardt 8% slo es
[G.S. 143-215.1]
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 perniit. 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 permi�t. [ 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 III,4. and III.S. of this permit. [ 15A NCAC
02T .0605(o)J
7. The compliance boundary is established at the property boundary. Any exceedanee of standards at the
compliance boundary shall require action in accordance with 1 SA NCAC 02L .0106. [ 15A NCAC 02L
A 107(i)]
WQ0022307 Version 3 A Shell Version 151201 Page 2 of 7
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)J
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
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
[ISANCAC 02�I .0219(j)]
b. The setbacks for storage and treatment units permitted under 15A NCAC 02H .0200 shall be as
follows (all distances in feet):
Any well with exception of monitoring wells:
ii. Any property line:
[l5A NCAC 02H .0219(j)]
III. OPERATION AND MAINTENANCE REQUIREMENTS
100
50
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
frotn the operation of this facility. The Permittee shall maintain an Operation and Maintenance Plan
pursuant to 15A NCAC 02T .0604(fl. [15A NCAC 02T .0604(�]
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. [i 5A 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 A 108(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 OZT .0605(0)�
WQQ022307 Version 3.0 Shell Version 151201 Page 3 of 7
5. Irrigation shall not be performed during inclement weather or when the ground is in a condition that
will cause pondin� or runof£ [15A NCAC 02T .0605(0)] -
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 I1.4. [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 .l 100. [15A NCAC 02T .1100].
10. Diversion or bypassing of untreated or partially treated wastewater from the treatment facilities is
prohibited. [15A NCAC 02T .0605(�]
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. [ I SA NCAC 02T .0108(b)(1)]
WQ0022307 Version 3.0 Shel( Version 151201 Page 4 of 7
IV,� MONITORING AND REPORTING REOUIREMF,NTS
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 Permittee shall report by telephone to the Ralei�h 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:
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. Auy 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 (800) 662-7956, (800) 858-0368, or (919) 733-3300. 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
be taken to ensure the problem does not recur. [15A NCAC 02T .0105(1)]
V. IN5PECTIONS
1. The Permittee shall provide adequate inspection and maintenance to ensure proper operation of the
�vastewater 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. GF,NERAL CONDITIONS
l. 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 .0110]
WQ0022307 Version 3.0 Shell Version 151201 Page 5 of 7
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 1 SA 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 NCG010000; 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)]
In the event the permitted facilities change ownership or the Permittee changes their name, a fortnal
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
.O 105(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 .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 exemplifes any of the criteria in I SA NCAC 02T .0120(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
.O 105(e)(3)]
Permit issued this the 14t'' day of December 2016
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
�' L?�:�.•��' •
�S. Jay Zimmerman, P.G., Director
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number WQ0022307
WQ0022307 Version 3A Shetl Version 151201 Page 6 of7
Permit No. WQ0022307
Steven M. and Rita B. Barnhardt
Heritage Harbor Lot D SFR
❑ Partial ❑ Final
Single-Family Residence Wastewater Irrigation System
December 14, 2016
Person County
ENGINEERING CERTIFICATION
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:
Professional Engineer's Name ,
Engineering Firm
Mailing Address
City
Telephone � E-mail
�
'�
, State Zip '
NC PE Seal, Signature & Date
TI3E 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-DI5CHARGE PERMITTING UNIT
Bv U.S. Postal Service:
1617 MAIL SERVICE CENTER
Bv Courier/Special Deliverx:
512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27604
WQ0022307 Version 3.0 Shell Version 15 i201
Page 7 of 7
State oF North Car�lina
Depariment of En�•imnraent and Natural Resoarces
Division otWater Resoarces
�� ]SA NCAC 02T.0600-SINGLE-FAA�tILY iiESIDENCE WASTEWATER IRfi1GATi.QN SYSTEMS
- OPERATION AND MAINTEIYANCE ACREEN[ENT
Dlvision of Water Resources FOItM: SFRWVti'IS O&1�108-13
Permit No. ��_v��__-1 z Z-��C % County: I''U �S�%�
Property owner(s) as appearing on the recorded dced: S Z� ��G �.� � l2/'c'�f�- ���.✓t��{-=�-2iJ j
Mailingacldress: �� �� S�ti�G !/v�(Cj� �FZ ��t,t P2L t•21 �`-l-z.�s.� /��C Z? Z/�
Facilit}- address:
Irrigation 3vlethod: (� SNRAY ❑ DR[P
I/ We agee to operate and maintain the single-family residence wastzwater treatment and irrigation system as follows:
The Pern�ittee is responsible for the operation and maintenance of the entire wastewater treatment and irrigation
system including, but not limited to, the follo�ving items:
a. The septic tank shall be chectced annuaily and pumped out as needed. ���
b. Thc sepiic tank effluent filier shall be ct�ecked and cleaned annuai[y.
C.�n S� u2�Cz.�e. �
c. Accessibte sand filter surfaces shall be raked and leveled every six months and any ��egetative �owth shall be
removed manually.
d. � The tablet chlorinator shall be checked �►-eekly. Waste��ater grade tablets (calcium hypochlorite) shall be
added as needed to provide proper chlorination (pooi chlorine tablets sha]t not be used), OR
❑ TE►c ultcaviolet disinfection unit shall be checked �veekly. The lamp(s) and quatta sleeve(s) shall be
cleaned or replaced as needed to ensure proper disinfection.
e. Al1 pump and alann s�•stems shall be inspccted monthly.
f. The irrigation system shall be insp�,cted monthly to ensure that the system is free of ieaks, that all irrigation
equipment is operating as designecl, chat vegetative grow7.h does not interfere wi[h ttte system inspection or
operation, that the soil is assimilating the disposed treated wastewater with no visible runoff �r pondin�, and
that no objectionablc odors are being generated.
2. Fai3ure to pay the annuat fee shal[ be cause for thc Division to revo(ce the permit pursuant to 15A NCAC 02T
A t DS(e)(3).
3. The Permittee's failure to pro�erly operate this syst:.m is subject to a peaalty up io $25,000 per day.
4. Failure to meet the permit conditions or violation of the State's surface ���ater or groundwater regulations may void
the pecmit.
AII owners annearioe on the leeallv recordc� aropertv deed sha11 siQn t6is Oneration & Maintenance AQreernent
I/ We understand th.e abnvc requirements arid agree to these tesms as part of the issued permit.
Owner Signalure: _ _.,?���-� �� ��1�`�����'�='� Date: - i� � (e
Owner Signature: ��Q. ����i,-r`i� C�'' Date:
FOR'vf: SFRVV\yIS O&hf OS-13 Page 1 of I
b'd Z9Zbb859££ p��oMe�n�iu�n�lunoosiQ dgb�609L£��nf
' ' '�rJQ Ot'.�2Z 3(� L�� D
-- - -- - --- ; ---- --- -- —
.
PROP. � �
PROPERTY \ �\SPRAY HEADS W/ RNNBIRD SLL20VH
UNE � 44DRILL NOZZLE.
_—� � 150�\ SO' SPRAY DWdETER ,. y�
. � / PROP. LJN WETTED AREA= � �a.
. � BUFfER 9.801 SF (0.22� i� s�/ �
t � t
� \ �
� ; Y � � �e.� �`�'��5.�'r{ } .
� �
� \ 1
� ♦ 1/�S D �=i+ � , �»',�x �i�� ������'� �n�
r `_' --- � � f , 'y x, w,y *t �r�, . ��.��a;
/ I� �i- ta �.j.
�� \ >;. � .frnf c3' G Zr ^�: t �� �
I v 1 �y` � � <�k��: r��J �� 4•
/;." 1
\ , \ \ lr' St�(e � �
,Y�' - ' OF
I� �'� s�'�.a: FlE
V .� � \�\ �� � BUFFERPTO BE
wniveR. I
� i \
�v APPUCATION ARFA SHALL BE
r � W(T}{ FESCUE OR
�'h°� r� � SUAI�IFAQyECETATION IF 3 4" X 3/4%7�
�i � / / � � IXISTi VEGEfATON iS �
/ � SPAR�OR NON-IXiS7ENT. � .
� � /
/ � /
.: � ` � % � � / 740'- 3(4/PVC PIPE ` � _ _ � /
/]6' M1N. COVER OWTO �OSTLJNE 1/ � � �
� (WHICHEVER IlGREATER) M'ffH �
� . / / WARNINC O��DERG OUND�PIPE /
/ / I �
/ / \ �. __
/CURVE DATA DEITA /��5 �� � CHD-BRG CHORO �
Ct 7GJ4 SO 50.00 66.83 47 504 SB't YE 61.96
110'42'00' S0.00 96.60 `�Z•14 NBt'23,23'E 82.26 •"�
C2 4g17�3' 25.00 21.Q3 1/.18 N50'0805•E 20.41� ���
C3 Z4?'S 175.00 7�k57 37.86 N62'Ot'17"E 74.OX
C4 ZT3�44� 150.00 72.42 36.93 N385B'SS'E 71,�7Y . 150' �_ �-Z, ^w
CS / � `OFFSEf /
/ � /
/ !
G �� �� ` c4 � ^
RP. I
I /
o PRN�� E. /
p5�
� o
l 1 .' � S�q13 PROP.O . �
WEII � /
�
I C� � C3 LpCAT10N ay�00 �ypYNE RAY MOORE �
'� TI,1: A23 19 �
J�T A,y ' \ n / PIN: 9070-02-98-3278.009
� sp � ' \ a� USE: VACANT �
�k5 C�i \ ' � 50' SETBACK �
y�'a�? ' � � �\ TREATIA� �
�\ � �480 � \ / Z / / /
� I ��� �° �� �� I
�_ —_`� AJ �
• ` ` — � — ,
1 LOT C i ' ( __._ — \ --'` "' � \ �
\ ` ' \ � .
� • \
\ `— _ _— � r' i � �
\ —f � i o � / �
� � � 1250 J+L,SWfIC TANN �;
\ r , � � / / �
Y�� � _1 �pROP 4'DtSQtBtlTfQA BOX ,� N
\ � \� -�yp�� '_' —� ! ' �� .0. l \ tpd µ,N. / / �
\ h 1 \ ,��y /�SN+D Fll1E I
b " � I�
Ex. ? n i ,�
N� W� � � /
U� LOCATIO O � 4• 7� N. � SE � �� _.1 p 2%CMiN. � M!
� WElla` ~_ --. — T9 C SEP/�tATION 2.44Q Gk.� 8 � /� Si
LOCATION � L � {pµF TANK � � �� RINATOR
� � % COMACi�BER /
� _�_�_� —� -- 1.578CAL � o' �
� \ � �, �, � �- � .. -STQPf`GE' M81'S0' �\ /
_�
�--- � TANK 43. �� 28�Y 92.it
��B•9?• � � � \ \ S�g16�20� 130. � j / / �
H690@• \ — �� S68'10'23 / / � � I
���14' 96'10' 'W 133 . � � �' � �
� �5 88" �_ �.� = �"' � SGT�--�
\` �_ r_ �
� � � 00� OF'f'SET
\ _� �
— -- FROM WATERUNE �, �
• 100 YEAR F1000 ElEVA710N PER � „�...�
FE{M MAP 37145C0075 8 DATEO .. —... �-' • 1
� --- _ ... ...t .�n .�...�..._' .. . .1___-
W C� pv�„z3o'?'
FILEO in PERSON Coun1y, NC
on D�c OB 2018 st D9:15A1 AM
b : fONYA R. NILSON
�GIS ER OF DEE03
Baok �9Q Pa e 121
ili IIIIIIIIIIIIIIIII�iIIlllfll! III
State of North Carolina
73epartment of EnvironmentaI Q�uality
I)ivision of Water Resources
N�N-�ISCHARG�; WAS'l['�WA�"�12 SyS1'EM V4rA�VER
(T/!/S FORM�LI,4)'BF, PNUTOC:OPIED FOR USF. AS�I�V OR/G/A%qLj
The Division of Water Resources r��ilt not consider this form complefe unless aTt iristructions are foilowed. Failure
to follow instrucfions or to subinit al! required itetns will tead to additiona[ processing and review time.
Fnr mvre in�nrrnutio� or fUr art eley7ra�ir version of thi.s ft�rm, vis•il uw• x•c�h si�r: a1:
hirn.:�: pvr�u/.1�cdei�� : n�/�a �elz: u•q/��n.ti'�/au�rapp/icul inn.s.
U�'STRLCTIONS T� TFi�: APPLIC�.NT:
✓ Da nnt submit this form for revie�v ���ithout a corresprn�ding Non-Discharge Permittin� Unit application fonn.
✓ Any changes to ihic fonn wii! result in the application package being returned.
✓ Any other setbacks required b?� 15A NCAC Subcliapter 02T other than those reFerenced bclow. cannot be waived
through execution ofti�is form.
✓ A copy ofthe comple[ed and appropriately executed li�nn musi be ro��ided to the rn e� �
__ — _ __ p P P m ow ner.
-�---��..
, ..� -�
AGREEMENT TO WAIVF, SETBACKS AS REQUIKED $Y
ISA ivCAC U2T .OSU6{a), .p50b(b), .0606(a), .0706(a) and .I006(a)
The undersigned properry awner(s) hereby permits:
tlpplicant's name: Steven M. & Rita B: Barnhardt
Complete mai(ing address of app]icant_ Iaerita�e I�arbor L,ot D on Clearwater 1 n(P__^_a__rcel No_ g9201
City: Semora �. State: NC Z� ' 2� '' '
p: _3a3
Telephone number: (336) 2G3-4245 Facsimile number: L )
Ziereinafter referred to as the Permittee, to (check all that appJy):
�J Non-Discharge dispasal nf h•aste�uater effluent within 0 feet of the property� [ine,
❑ Non-Uischarge disposal of wasicwater effluent v��ithin Ceet of the identi�ed residence,
❑ Construct treatment and storabe anits within feet ��f the property line,
❑ Construct treatment and storage units within feet of the identiiied residence_
FORM:NOWSW lU-Ib
Paae 1 oF2
800K 940 PAGE 122 36802�
T�e �Yaived setbacks apply as shown on the attached map and located at the followiug:
Location address of property: Heritage Harbor Lot C on Clearwater 1 n Larcel No 9919)
Cit;�: Semora , State: NC
— Zip: 27343
� I certify that 7 am a deeded property owner of above-referenced property and am authorized t� makc decisions regarding
this pruperty on behalf of other deeded property owners. Furthermore, 1 cercify that t 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. T further a�ree that I will record this waiver form with the a�opriate Re ister of
Deeds and nrovide the Permittee anri niv;c�nr, r,f warPr no�,,,.....,,,. ...:.L �_ _ ..
Property owner(s) name(s): �'� v �.
Signature: .' �.�Q�),✓t
Signature:
I�ORTH CAROLtNA,,J�_ �c�,n„r;��.. COUN?Y
'C� ,ti �Ct
Date: _ !1' � � •-j (P
Date: !4- ���) (,,
f, rJo In�c-f'L.c� ����w__�__ __. a Notary public for�� �,�. County, North Carolina,
do hereby certify that S:�-z ��-. q.n, c_. �_.�.k, %3•,,,.�c j,....
.,�i— personally appeared before me this day and
acknowled�ed t1�e due executiori af the f�regoing instrument.
Witness my hand and official seal this the Z'a
day of ll.���e„� fy��- 2�'/b
- __� �_.
� G ` .�T
' ratu�e of Natary Pub(ic
NI}7 COYl1/TIfSS1Ul1 Ca.PITQS VGj �+ /�j ^� zU��
Uocument sho«s proof/acknou�icdgcmcnt bctbrr
ofticer authori�.cd to take prouf/ac;kno��ledgement:
acknowlcdeemen includesoflicer'ssignaturr,
�� �comi . ion e. •pirali n da • o • al seal, if required.
I,uo, ersun C'ount�- Register �,f Decds
FORM: �llWSW 10-16
Page 2 of 2
�r�t� oo. �.:?' av 7
FILED in PEHSON County, NC
on D�c OB 2�18 tt 0915:08 AM
b: f ONYA R. WIISON
�ok 5��0 �a e 125
iii iiiiiiiiiiiiiiiii�iiiiiuiiiia
State of North Carolina
Department of Environmental Quality
Division of Water Resources
NON-DISCHARGE WAST�WATER SYSTEM[ `WA.I'VER
(Tt11S tORMM.4)' L3E 1'1�07'UC��PIED FOR USE�lS�1tVOK/CI:�VALJ
The Division of Water Resources will noi considcr this farm camplete unless ali i.astructions are followed. �'ailure
to foltow instructions or to submit all required items fvill lead to additional grocessxng anci review titne.
For• morc infa•mulinn or,for un eleclrc�r�ic i�ersron of'lhis far•�n., irisit nur lreh site oi:
h!/p:: : 'vnrl uL �tcderv_��r�u_eb,ii•c�ans9aulcrnnlieu�i�n r.
INSTRUCTIONS TO THL APPLICAI�T:
✓ Do not submit this form for review� without a c�rrespondins; Non-Uischarge Permitting t�nit application form.
✓ Any changes to this form will result in thc applicalion package heing returned.
✓ Any other setbacics required by ISA NCAC Subchapter p2T other than those refenneed belo���. cannot be waived
through execution of ihis form.
✓ A copy of the cornpleted and appropriately eaecuted form must be provided to the propertv owner.
AGREEMENT TO WAIV� SETBACKS AS REQUTR�A BY
15A NCAC OZT .USQ6(a}, .p506(b), .OG06(a), .0706(a) and .1006(a)
The undcrsigned property owner(s) hereby permits;
Applicant's name: Steven M. & Rita B. Bamhardt
Compiete mailinD address of applicant: HeritaQe I��rbor Lot ll on Ctearwater Ln (Parcel No 992p� _ �—
City: Semora _,_ __ State: NC —�
.-_ Zip: 27343 ,
Telephone number: (336,� 263-4245 Facsimile number: �_� 1— �
Hcreinafter referred to as the Permittee, to (check atl that app]y):
��Ton-Discharge disposal of ���asiewater eftluent wiihin 1.00 feet of the property line,
❑ Non-llisc�a be disposal of wastcwater efEluent wit6in feet of the identified residence,
❑ Construct treatmeni and storage units within ' feet of the property linc,
❑ Construct treatment and storage units within teet of the ideniificd residence.
FOR,'vI: NDWSW 10-16
Page ) oi'2
BOOK 990 PAGE 126 36803�
Ti�e waived setb3cks ap�ly as sbown ou the attached map and located at the fol}ov�•ing:
Location address ofproperh�: }•lerita�e Harbqr Lot on Clearwater 1.n. Parcel No. 9918)
City: Semora _ State: NC
_, Zip: 27343
� 1 ceriify that I am a deeded property owner of above-referenced property and am authori;ced to make decisions regarding
this property on behalf of othcr deeded property owners. Furtherm�re, I certify that ] have read and undeistand this
Agre;,ment and do hercb}� grant permission to the Permittee to dispose of wastewater cfiluent or constrvet wastewater
rreatrt�ent units as specified herein. I further agrce that I will recon3 his wai.��er form with th�anpro riate Register of
Dceds and. rovid� the I ennittee and Division of Water Resources w�ith documentation of such.
Pr�perty owmer(s) na }: �� C� a e �' , �
�Vv14����� � �
Signature:r �f' -�"—
Signature: � — . Date: _ t �� _
/ ---- — -- Date: II K (`
VURTH CAROLINA, �(J,�_C�� _ �` CO��TY
i, i't5Y1� � ���j
�.--i "��`� . _ a �a�arv Public
do herebvi certifi� t , �-4 I,`_
. „ hat ��_�__ ��(`� l��
aci:no���tedQed t�le due c.��-e�cut � fuaYrlorOn �niJ�.�p� �nn�i.
.. �Yl
�0i ���=- County, 3�orth Carolina,
__..._.___ personallv appeared before me this dZy and
N'itness m}� hand and oflicial cea) this ihe da,. �,r �r �
-�_:._ _Nq��,� _ a � �.
SE.�L
ASNLEY E MONACO
Nor�Y Pua�c .,
� �� s
A�' Conrniss�on Ex�ir�s Oet. �6� �0?.Q
r;�fttv;: �UN'SW IO•}6
�
Srg,rarure o . 'vtary• P /����1
13�1�• cammission erpire.r ��
'_"_��� ,
lk�cument shows prool�iacknowledgentent before
afTiccr auchorir.cd tu iake pruoflucknc�wicdgcmcnC
acknuwiedgcmcnt includcs uliiccr"s sienaturr,
com ��n expirati m d• • icia) sea . if required.
'fo�lsnn. 1'enun (. ou»t�• Rcgi�t�r of Uecd�
�'�gr 2 of 3