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ETNOTE, A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION. Date: a-1Q'3 - I a Proposed. Buyer or Business Name: 4 ~YYl Y } tdeV5 Applicant/Mortgage Co: Ed'1 AE'ln-,v.-er. Mailing Address: _ 10 j _ r5 /--V-1 S RV2 . City: _ 7)14 g, State: A) - C• Zip: Telephone: O SAO- 3&6 1Other ( } 2Y 6 - B~a- 6 7 CZ~ Current Land Owner: , 7o hnriv Min ftys Phone: ?f6 Property Address: r-b 11 At r -d L PIN: 1615•--'5? ",a'Sas Panel: State Road State Road Name: Name of Subdivision: Lot # _(If Applicable) of piKoyees # of children it of em ovees~-- of.seds_ Directions: (please give concise, complete directions from Lillington, NC to the property) L4 'a t -i t v~d Ztm n , cress c)Uer tali l r©gcI 4r4c,V~6 i n Nnrl -Turn i G rn 1 tJ. r r t `ty r 1% 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: E~'t FOR OFFICE USE ONLY AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM ignature of Environmental Health Specialist Date SEPTIC 14 11 4/tlA