ETLIJI/~ ► 0 /0 ( Application # V 2 ~lD
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
. ETC.
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: Z 9 0 I
Applicant/Mortgage Co: b~E~eNEG[. ~1.c:.wv~ - ~y~~~t s T~zA~4E2 '1 a~ K
Mailing Address: ;ZSY 12f1YMt tuD Aver-y ~R V
City: EP-'UJn! State: A-/ N-C Zip: Z 5':139
Telephone: ( ) 2 10 - 997 - S'Other ( )
910-=?8S- 6374
Current Land Owner: Phone:
Property Address: I- C T ( 6
PIN: Parcel:
State Road State Road Name: V RAlALJ- `TT)
Name of Subdivision: Lot 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. 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.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
C' (r [0"Wh 4 Z " I-
of Environmental Health Specialist Date
SEPTIC
e~ D9792o
a~~ y /o C/ 4/08
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