NEW WELL UI�a g est,SdoLI-Li 1o1
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
\� � (ST( )“�
App
�+Dif t °� Phone Number
ppp ant/Owner \,)0.11 0.- \
Street Address,City,Stat; Zip Code
b It St[e Plan. The Site Plan is a map/drawing of the property and must show;
The Applicant and easements with dimensions;
2.the existing son of proposed property andap
the location of the facility and appurtenance: sed well;
3.the location for the proposed well;
4.the location of 5.the location of any existor ing wellsed wit witr lines hin fee and/or f the property;disposal
surface water bodies;100 feet ort the props
6.above ground and/or underground storage tanks;
7.and any other known sources of contamination within 100 feet of the proposedor w
The Applicant shill uodfy the Harnett County Health Director throughby 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 are landscape changed that affect site drainage.
Contacti Environmental Health Division-910-893-7547
PROPERTY INFORMATION
Proposed use of well
Single-Family/
MultifamilyC Church L. Restaurant ❑ Business ❑ Irrigation C
q5 ._c _Subdivision/Lot#�
Street Addres PIN#
Parcel#
Direction
•
O
els
1 itaisrprilMJ ‘a
have thoroughly read and completed this Application and certify that the Information provided herein is true,complete and
correct to the hest of my knowledge and is give in good faith. Representatives
eprese os to determine oftheHaomep�nCounty Health
apt D bye tment and
state officials are granted right of entry to conduct necessary pea
I understand that I am solely responsible lite the proper identification and labeling of all Property lines,underground utility lines,and
making the sire accessible so that a wills n be properly constnicted according to the permit
g —tea'Nei
DateProperty Owner
fOnmer's Legal Represen Signature Required
HARNETT COUNTY CASH RECEIPTS
*** CUSTOMER RECEIPT ***
Uper: IBROCK Type: CP Brawn: 1
Date: 6/22/18 52 Receipt no: 399885
Year Number Pmaunt
2016 500441Bi
95140 *UNASSIGNED
FUOUAY-VARIHA NC 227526
24 BP - ENV REAL Tv ''EFS
4250.80
NEN WELL
SPENCE HARRINGTON
Tender detail
CK CHECK PAYMEN 6760 •250.00
Total tendered
Total payeent 1250.00
Trans date: 6/22/18 Time: 1.2:44:54
** THANK YOU FON YOUR PAYMENT **