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ET53 Application # Oq 50 © `.Z V B HARNETT COUNTY CENTRAL PERMITTING PO BOX 65 LILLINGTON NC 27546 (910) 893-7525 FAX: (910) 893-2793 www.hamett.org/permits ~o Neer APPLICATION TING S YYTEM INSPECTION FOR MORTGAGE COMP OMMERCIAL CHANGE OF D O FIRED TC. AL DAT E NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME,O,FyA,PPjLII APPLICATION. Date: I. 4 °1 rn~ , Proposed uy~ er i e: Applicant/Mortgage Co: Mailing Address: City: Telephone: ( ) Current Land Owner: Property Address: _ PIN: -Pc 5 bfS-1-~ State Road Name of Subdivision: Daycare: # of empl Restaurant: tof-err Directions: -State: Zip: Other k ( ) )110,W Z -14 / - ,e Phone: G C, .ez Parcel: State Road Name: rs• # of seats Hours (If Applicable) 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 corre Signature of Owner, Authorized Agent or Applicant: vkzlpe~~~ FOR OFFICE USE ONLY AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM 'j Signature Environmental Health Specialist Date SEPTIC 412'hoCJ 5 4/08