ETP
Application # 1 2 v 2 J 0
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnett org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FO ,
ETC
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
Date -3-23- 12,
Appl>cant/11~
Mailing Address 4~
City 1'#4 - State
Telephone ( ) Other # (
'i 1 Dc/11 Parcel
State Road Name
Current Land Owner Zz / e_ so/ I,Y w rV Phone '711 - ✓q y 7~~
Prnnertv AddrPCC .7'7.9 a :2 '4 GLUe. 77Jine---
L
PIN 15UX
State Road # 'x
Name of Subdivision
of
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
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
MA7-1_~ 2-
of Environmental Health Specialist Date
SEPTIC
Zip ~4~
J
Lot # (If Applicable)
4/08
Directions (please give concise, complete directions from Lillington, NC to the property)