DOCUMENTS 3l I r? irispot4-1-159
Harnett County Department of Public Health
Well Construction Permit Application
If the information in the application for a Well Construction Permit is falsified;
changed,or the site is altered,then the Well Construction Permit shall become
invalid.
APPLICANT INFORMATION
Joe Gregory ( 919 ) 227-6722
Applicant/Owner Phone Number
2812 Carson Gregory Road,Angler, NC 27501
Street Address,City,State,Zip Code
The Applicant must inbuilt a Sas nag. The Site Plan Is a map/drawing of the property and must show:
I.existing and/or proposed property lines and easements with dimensions;
2.the location of the facility and appurtenance;
3.the location for the proposed well;
4.the location of existing or proposed sewer lines and/or sewage disposal systems within 100 feet or the proposed well;
S.de location of any existing wells within 100 feet of the property;surface water bodies;
6.above ground and/or underground storage tanks;
7.and any other known sources of contamination within 100 feet of the proposed well site.
The Applicant shall notify the Hansen County Health Director through or by way of the Harnett County
Division of Environmental Health If any of the following occur prior to well construction:
I.there is a relocation of the proposed facility;
2.there is a change in the intended use of the facility;
3.there is a need for installing the waste water system in an area other than indicated on the well permit;or
4.there we landscape changed that affect site drainage.
Contact information: Environmental Health Division-910-893-7547
PROPERTY INFORMATION
Proposed use of well
Single-Familyt) Multifamily: Church J Restaurant ❑ Business L Irrigation C
Street AddressPS �? (y.M W\&Mt%tikikdivision/Lot#
C
Parcel# Y/ Mantra bc-i err#ti.octa. ' o�O•tJ(50
Directions to the Site
North on NC Hwy 55 from Coats to right on Carson Gregory Road. 2.8 miles to white house on right.
See attached Google map for planned well location and septic tank location.
I bare thoroughly read an completed tin Applicants sad certify that the Infurmalbe provided kerns b tne,complete gad
correct to the best of my hauwbdge ad is give is pod with Rmranded's of Oe Hanel Comity Health Department sad
Mate officials an granted right of ntry le conduct Necessary stpeadoas to determine compliant with applicable mita
I aMerstmd:has/an.solely responsible fir the paper idea:Oration at labeling of allpropery lines,underground utility lints.and
making the site accessible so that a will can be popery cwamried according to the permit
aL/�j/I'atp July3,2017
/aopw Owmn'e of 's Leal Representative Sig name Required Date
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