ETp( Application # J~~Q CQ
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.orglpermits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
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NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION. `Do [
Date:, _ "
Buyer or Buss N
Address:
State: / Zip:
Current Land Owner: /C~
Property Address: ~Q 1)w
i°- PIN: J`(O 'S' - n-2 S OW: O CYO Parcel:
State Road L a0 , State Road Name
Name of Subdivision: ~Yt
a care: # of em ees # o ildren
R taurant: employees # of se
Directions: (please give concise, complete directions from
e~r6 _ `7 f 1, , r a A l,• A X
rLOt # (If Applicable)
ours:
Hours:
llin on, NC to the property)
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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 Applicant:
4"-P~ 01- (Z
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environmental Health Specialist Date -T-
SEPTIC 4108