DOCUMENTS ` 1 k 1 cl l r OL aLo1 L
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
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Applicant/Owner Phone Number
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Street Address, City, State, Zip Code
The Applicant must submit a Site Plan. 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;
5.the 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 Harnett 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:
1.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 are landscape changed that affect site drainage.
Contact information: Environmental Health Division -910-893-7547
PROPERTY INFORMATION
Proposed use of well
Single-Family Multifamily Church Restaurant Business 1 Irrigation
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Street Address 1)7D rEpcA,Mers to .�X1 Subdivision/Lot#
Parcel # 13 ()SCA exY7l Q3 PIN # OSlcl - e �) -Jaoa..moo
Directions to the Site
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I have thoroughly read and completed this Application and certify that the information provided herein is true,complete and
correct to the best of my knowledge and is give in good faith. Representatives of the Harnett County Health Department and
state officials are granted right of entry to conduct necessary inspections to determine compliance with applicable rules.
I understand that 1 am solely responsible for the proper identification and labeling of all property lines.underground utility lines,and
m •� the site accessible so that a will c be pro h constructed according to the permit.
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Property Owner's of Owner's Legal Representativ gnature Required Date
NOT FOR LEGAL USE .
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