ETApplication 2 Z
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnett org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES, 1M 11-0@1111t @N9, PM
40"O@ftsimp. F180 ETC
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
Date Z /L
Proposed Buyer Sc 01/0-1 ~ 1 1141 q.11
Applicant/Mortgage Co
Mailing Address 42-6Z
City g iin I2aInQ State N C Zip 27~~ 1
Telephone (q1yJ2"2& -5344 Other# ( )
Current Land Owner
353- L1Z 77-
3
PIN -72 State Road #
Name of Subdivision
L, °ra Parcel
State Road Name
'>lIf Applicable)
Directions (please give concise, omplete directions from Lillmgton, NC to the pro erty)
42-1 !U/9 P- ~ P. t? on r D g M / l ( r~ (f 6 r-C
There is a $100 00 charge for this service This approval is subject to revocation if the
intended use of the septic system changes or if false information is provided on this
application
Your signature below certifies that all above information is correct
Signature of Owner, Authorized Agent or Applic
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
ignature of EHVi'roninentai Health Specialist Date
SEPTIC 701 g_
0h d