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HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION p af YJ
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NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: g1r,
RNP-91-d BU3*;-_Q-f Business Name
Applicant,4~4e~EgaFe:/Ifs ` d G Age-
Mailing Address: An. 4,44 Z:2 2
City: ,rsde~Ak--,Q Stater',& Zip:
Telephone: (9/i Other ( )
Application # le-9. .i,6 22 &
Current Land Owner: ~14N/!L d ~40irm 5 Phone: t / 1 L 1 5' t...-
Property Address: GG3 G &e- N'4 7
PINJG5. ' - Parcel: - .
State Road to oad Name:
Name of Subdivision: S T Lat # (If Applicable)
of en
# of
children
Directions: (please give concise, complete directions from Lillington, NC to the property)
aI0 -rya.., aAa. iA,d - R161sT 041 Oell.¢101,f 141J.
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 c rect.
10 4
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Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
V-30-1 Z-
of Environmental Health Specialist Date
SEPTIC / / 4/08