ETApplication
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HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnetf org/permits
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 1 6 - / Z-
Applicant/l S_ A~, - l
Mailing Address S~3 S -A10' 210 S
City uklKII State
Telephone Oio) St 4 i o0% Other # ( )
Current Land Owner
PIN v / - L(0 90 XO Parcel 0_
State Road # L 21/7 State Road Name _..:&G
Name of Subdivision
# aivemnloovees_ _ #
s jL5
-zip
'hone
# (If Applicable)
Directions (please give concise, complete directions from Lillington,^NC to thy property)
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
Signature of Owner, Authorized Agent or Applicant
FOR OFFICE ONL
AUTHORIZATION FOR USE OF EXIS G SEPTIC SYSTEM
tore o E vir en Healt Speciah t Date
SEPTIC ()f 4/08
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