ETAPPLICATION 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.
Proposed Buyer or Business Name:
Applicant/Mortgage Co!)
Mailing Address: ,
r
Date: f 7 J -a- ck)
f%6; -
City:
Telephone
State:'
Other ( )
Current Land Owner:
Property Address: j ( fit. c~
PIN: 0 ctn.
-e -115 t36 0 Farce : ~b`-L
State Road I b t State Road Name: CA- C.
Name of Subdivision: - -_n,
a e f emplo es # ch ren
e aurant: of e loyees # of seas"-_-,
Directions: (pie se ive concise, corplete di ions from Lil
Zip:
?hone.
)r'
4-5
# (If Applicable)
Hours
~Ql~l,.3'l ~ 4 a
n, NC to the vroperty)
0- (Y"~ 61 c£ S +Z-;k(,_ _ /,-s L"-v <cJ ,t J d o
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:
/~lr~-------
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
of Environmental Health Specialist Date
SEPTIC
4/08