ETApplication # r Z 2P Z J`
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date:
Proposed Buyer or
t r'a't
City: -C.c~?
Telephone:
Current Land Owner:
PIN: Vto 3V -
State Road 12- _
Name of Subdivision:
Da ca = # of ioy
iraRtl-of a oyi
I?irections:. (please give
t ~.S
airy State: Wj Zip:
Other k ( )
V Parcel:
Road Nam(
_(If Applicable)
seats I / Hours:
from Lillington, NC to the
1 A A 2. }n 6-<,o iJ 6.d - r\J .
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 informadon is
Signature of Owner, Authorized Agent or Applicantk-if" V Vl.J 0 ff-J4, k 10
FOR OFFICE USE ONLY
h ATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environmental
SEPTIC
4/08