ETApplication 50C 2-Q 154
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/pennits
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: (a • 14 .12-
Proposed Buyer or
Co:
Mailin Address: ( f FA -ThomS Kok
City: a mQyriy~ State: ' j)C Zip:
Telephone: (q 6 "la l - ` s(oq Other ( )
Current Land Owner:
PIN: L,, ~7 (/X Parcel:.-10 i
State Road #.U10 2,1 - State Road Name: 0 ,
Name of Subdivision: Lot # -(If Applicable)
# of
ve
Hours:
Lillington, NC to the
There Wa $100.00 Marge 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. / /
qa"
Signature of Owner, Authorized Agent or Applicant: I
t 7~crx..(
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
19
~-tu-r'e of Environme ealth pecialist Date
SEPTIC /08
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