ETNOTE; A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: / - /Z 12-
Proposed Buyer or Business Name:~ °
ApplicanuMortgage Co:
Mailing Address: ~O R x 1®5'7
City: P*- 1 b f, State: n) Zip: 'Ago*
Telephone: (qJ *7!7 Q. op R Other ( )
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Current Land Owner: --Phone: 7oV 9$ 2•
Lt
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P1N:~ LIIALI 000 Parcel: `
State Road #:-VL-2 -State Road Name:
Name of Subdivision: Lot # - (If Applicable)
Restaurant: # of employees_- -4~_ # of seats 1 2 Hours: !5 w O
Directions: (please give concise, 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 information is correct.
101% A
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
TION FOR USE OF EXISTING SEPTIC SYSTEM
Signature o nvironmenta lth Specialist Date
SEPTIC 4108
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