NEW WELL 51d2- 1 )Y a56043g51
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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ApplicaWOpwner Phone Number
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Street Address,City;State,Zip Cote
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 Harness 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 are landscape changed that affect site drainage.
Contact information: Environmental Health Division-910-893-7547
PROPERTY INFORMATION
Proposed use of well
Single-Family'MultifamilyL Church E Restaurant L Business LI Irrigation L
Street Address Subdivision/Lot#
Parcel# OCD 0S2(0 oiS% c PIN# Oc9(0 — 33.crib
Directions to the Site
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 l am solely responsiblefor the proper identification and labeling o/ail properly lines,underground utility lines,and
making the site accessible so that a will can be pr oerly consouned according to the permit.
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Owner's of Owner's Legal Representative Required Da
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HARNETT COUNTY CASH RECEIPTS
*** CUSTOMER RECEIPT ***
Goer: TBRGCK Type: CP Drawer: 1
Date: 5/22/18 52 Receipt no: 364930
Year Hummer Amount
2818 50043959
95125 *UNASSIGNED
DUNN, NC 28334 - ENv HEALTH FEES
F4 4250.00
HEW TANK
LAMOOTH M O'NEAL
Tender detail $250.110
CP CREDIT CARD 4250.00
Total tendered 4250.08
Total payment
Trans elate: 5/22/18 Time: 41:06:84
** THANK YOU FOR MLR PAYMENT **