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Application
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HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/pernlits
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date:
Buyer or Business Name:
Mailing Address:
City: .90
Tel . ( ) .
State:
Other ( )
Current Land Owner: Phone:
Property Address:
PIN: K- 24 1 I O Parcel: Q 0
State Road State Road Name: jqi v
Name of Subdivision: Lot # _(If Applicable)
Directions: (please give concise, complete directions from Lillington, NC to the property)
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There is a $100.00 charge for this service. his approval is s ect 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.
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Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
S h SPeciali st Date
l Healf Enviro menta
SEPTIC 4/08,
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