ETApplication # M.
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
FOR MORTGAGE COMPANIES, COMMERCIAL CHANGE OF
OWNERSHIP, FIRE DAMAGE, ETC,
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: 31 17 )z -.O 1
Proposed Buyer or Business Name: 0 me.11ct.. JadW 1
Applicant/Mortgage Co: 6-u--
Mailin Address: --2 E. B&~Q OA St a
City: State: E,.- Zip c)7,5 a 4o
Telephone: (91q _ ~ ~ , - 41b1 Other fNB 414 - J?
B 7 ~ _ Current Land Owner: Q .u0~ n LOan 5ervjcr n Z.L.Q. Phone:
Property Address: t in O F - V J -7 5
PIN: C 1 " t" . cc I I . Parcel:
State Road State Road Name:
Name of Subdivision: 01; ~ 8 ra n C-.11 Lot # (if Applicable)
Daycare: # of employees' # n-auMmµ"-
Restaurant: # of employees= of seats Hours:
,Directions: (please give concise, complete dire ' rani Lillington, NC to the property)
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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
AiAra , /?r<
3
Signature of Environmental health Specialist Date
SEPTIC
t
4/08
i 2- 0