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pplication # a4 5 0 0~ i g 3 p
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/permits
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NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: -Z ci M At r nt C e
Proposed Buyer or Business Name:
Applicant/Mortgage Co:
Mailing Address:
City: State:
( ) Zip.
Telephone: ( ) Other k
Current Land Owner:.~so„~
Property Address: 11,11 Ly Aar Phone:_ ~1/g
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PIN: Parcel:
State Road State Road Name:
Name of Subdivision: Lot #
(If Applicable)
Da car : # of employees # of children
Restaurant: # of employees # of seats Hours:
Hours:
Directions: (please give concise, complete directions from Li lington, 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
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
of Environmental Health Specialist
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Date
SEPTIC J 3131 10q
16)f 4108
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