ETIX ors
Application #
HARNETT COUNTY CENTRAL PERMITTING a
PO BOX 65 LILLINGTON NC 27546 ~&-evptv&t
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6 (910) 893-7525 FAX: (910) 893-2793 www.harnett.org/pen -nits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION v-- -3v
FOR MORTGAGE COMPANIES COMMERCIAL CHANGE OF
OWNERSHIP, FIRE DAMAGE, ETC.
NOTE: AD 7OR O FER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date:
City: A t-4
Telephone:
State: .✓V& Zip: --7
Phone:---9/19 575
Current Land Owner:
Property Address: vss
PIN: I " S~. T- loll 3. t> Parcel: (L)
State Road State Road Name:
Name of Subdivision: Lot # (If Applicable)
# of
Directions: (please give concise, complete directions from
NC to the nrnn,-rtvl
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There is a $100.00 charge for this service. This approvaris subject to revocation if the
intended use of the septic system changes or if false information is provided on this
application.
Your signature below certTies that all above inform
Signature of Owner, Authorized Agent or Applicant
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
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` nature of Environmental Health Specialist Date
aton. is c reet.
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SEPTIC
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