ET- N- I D- Application # / cis f L& PC Y33
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www,harnett.org/permits 5 1c~o-
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES COMMERCIAL CHANGE OF
OWNERSHIP FIRE DAMAGE ETC.
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date:-,
.
Buyer or Business Name:
Mailing Addr ss
City: ~,l
Telpphon( )
St,
Other (
Zip:
Current Land Owner: - .I'~"I /C'c,,j,nPhone:/'G~
Property Address: _2 J .c 1 r 1" ,17c~r~ r ~ z..S..T ~f
oLD
PIN: 11C 4~ mrParcel: /a~ L?_
State Road State Road Name:
Name of Subdivision: Lot (if Applicable)
f children ~Hours:~~ ~
Daycare: # c~f'e loyees , _ _ _ l l r
Restaurant. # of e loyees f seats Hours:
Directions: (please give concise, complete directions from Liilington, IBC to the property)
/
There is a $100.00 char a for this service. This approval is subject to revoca ion if the CII-A 474
~
intended use of the septic system changes or if false information is provided on this_
application.
Your signature below certi fres that all above in formation is correct.
Signature of Owner, Authorized Agent or Applicant:
I--
FOR OFFICE USE ONLY'
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
of Environmental Health Specialist
e
Date
SEPTIC !08
i~