ETApplication CpiSUU a t u r}S
510c,
HARNETT COUNTY CENTRAL, PERMMING
PO BOX 651,111 NGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamen.org/perraits
APPUCA110 FOR EXISTING SEPTIC SYSTEM INS' TION
FOR MORTGAGE COMPANIES. COMMERCIAL CHANGE OF
OWNERSHIP. FIRE DAMAGE. ETC
NOTE. A }DEED O OFFER TO PURCHASE IS REQUIRED AT TIME OF APPIIC4770N.
Date: ~ 1 Z) :;:z ab 01
Proposed Buyer or Business Name:
ApplicantlMortgage Co: C7 t-_ d e.;- 8A 1 L c, c~,~ k a,
Mailing Address. WOLO
0
City: State r*`"__ -Zip:-,
I;k°7 _311.2 0
Telephone: (m,o) 4 L4a a3 Other (q») n~1 S - °I Ss
Current Land Owner.
Property Address: -
PIN: U fit. ~ - 2j.
State Road #:.Q z-~_\:
Name of Subdivision:
#
# of
AA%Mbtm)
Hours:
Directions: (please give concise, complete directions from Lillington, NC to the
Your signature below certifies that all above in, fomiation is
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signahm of Environmental Health Specialist Date
Parcel:
SEPTIC 4108
There is a $100.00 charge for this service. This approval is subject to revocation N the
intended use of the septic system changes or If false Information Is provided on this
application.