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Application #
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (91.0) 893-2793 www.hamett.org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES COMMERCIAL CHANGE OF
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OWNERSHIP, FIRE DAMAGE, ETC.
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: 441 -0?a- t
Proposed Buyer or Business Name:
Applicant/MaAgage-Co: V .
Mailin Address: f-9.8
City: State: Zip: aPY53 CD
Telephone: eA '?l 9 -Other k (4:DO 8W Si
Current Land Owner: Phone: 7C
Property Address: 3
-
PIN: LL) Parcel: ' i
IL7
State Road k--1 i' J State Road Name: L,K'
Name of Subdivision: Lot # (If Applicable)
a car • o~°mployees # of children Hours:
~estrant: # o `anployees of -sea °`ts Hours
(please giveSoncise, complete directions from Lillington, NC to the 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 infornation is orre
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
1 5-=~4 z..
4 1A-,-A2f!S7
of Environmental Health Specialist Date
SEPTIC 4/08
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