ENVH WELL REFUND1
f"ORTH CAROLIP!A
Account Number:
Project Number:
Vendor Name:
Vendor Number:
Remittance Address:
Date 1 -29 -13
110 - 0000 - 345.18 -00
Richard Green
1217 Chicken Farm Road
Dunn, NC 28334
•
oMail to payee
Check to be picked up by:
(Requires approval of Finance Officer)
Approved: Disapproved:
Reason for check request: Well drilling started without permit. Applicant states they have ceased to continue
installation of well at this time.
This check request has been examined by me and is hereby approved for payment.
Department Head or Authorized Designee // Date
Graham H. Byrd, R.E.H.S. or Authorized Designee _/L__ �. C. / �7J.
This instrument has been
preaudited in the manner required
by the Local Government Budget
and Fiscal Control Act
Harnett County Finance Director
Description
Amount
Well Construction Permit Fee
$ 250.00
Site Address: 1195 Chicken Farm Rd - Dunn
Application # 13 -5 -30409
Total Amount Due
$ 250.00
Reason for check request: Well drilling started without permit. Applicant states they have ceased to continue
installation of well at this time.
This check request has been examined by me and is hereby approved for payment.
Department Head or Authorized Designee // Date
Graham H. Byrd, R.E.H.S. or Authorized Designee _/L__ �. C. / �7J.
This instrument has been
preaudited in the manner required
by the Local Government Budget
and Fiscal Control Act
Harnett County Finance Director
!:s ; �v;fo y r;9
Well, Construction Permit Application
If the information in the application for a Well Construction Permit is fats #7ed,
changed, ar the site is altered, then the Well Construction Permit shall become ,
invalid. !
APPLICANT INFORMATION
Applicant/Owner '� Phone Number
Street Address, City, State, Zip Code j ,s�
The Applicant must spbmIt a Slte Pian. The site Plan Is a map/drawing of the property and must show: 111
v
1. existing nd/or proposed roe lines and casements with dimensions;
8 t po property appurtenance;
2, the location of the facility and appurtenance; + +J
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 too feet of the property; surface water bodies;
b. above ground and/or underground storage tanks; Aefi�-
7. and any other known sources of contamination within too 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: —4—
1. there is a relocation of the proposed facility; j
2. them is a change in the intended use of the facility;
3. there is a need for instalUng 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 - 8937547
s
PROPERTY INFORMATION
,,Proposed use of well
Single - Family: MultifaI Church ❑ Restaurant Business D Irrigation 7
Street Address /�1� C" � 1. Subdivision/Lot #
Parcel # � �- /�' � �f �' 2 PIN # j5A2 � 3 ' d f
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 applies bit rules.
I understand that I am solely responsible for the proper identification and labeling of ail property lines, underground utility lines, and
making the site accessible so tI can be properly constructed according to the permit j
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112312013 3713;13 Pal
Application number 13 50030409
Address 1135 CHICKEN FARM PCB
02
Position to
Starting characters
mount
Previously
To Appl Description
Applied
Paid
.�
CP))x MISCELLANEOUS
V w
.00
.00
=,0 CREDIT /DEBIT PR ®C, FEE
.00i
.00
E WELL FEE
250.00
250.00
tI EV RETURN TRIP FOR SEPTIC
»00
,00
EXIST. TANK TEST/INSP.
� 00�
.00
FMx AUTO FIRE EXT SYSTEM
00 ;
.00
FM DAYCARE INSPECTION
.00
.00
FMx EXPLOSIVE MAT 72 HISS
00'
.00
FMx EXPLOSIVE MAT 90 DAY
o0 `"
.00