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HARNETT COUNTY CENTRAL PERMITTING
PO Bolc 65 Lillington, NC 27546 O n 5~~
910-893-4759 Fax: (910) 893-2793
NO Ms WHEN APPLYING FOR A Waff1NGyZM j JA K INSPECTION FOR A MORTGAGE Cgh2MV A nr9n
OR OFnR TO PURCHAM Wffl.r. BE REQUIRED
Date: 4k3otoct
Telephone: ) ?7 ~3(iohn Fax: FQ-3-7 n _163a
E-Mail:
Applicant:
Maili Address:
City: ~1 I~1 r Zip Code: 2
Property Owner: As listed in Tax Office)
Property Address: -Ke.W 4 AA MY
State Road Number: Lot Number:_
I
Name of Subdivision: Q k\ (if Applicable)
directions from Lillington, N.C,)
There Is a W.OO charge for &M servlce. 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 i c rrect.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
for Use of Existing Septic System
09/03
5
Signature of Environmental h Specialist pat
s" -g to qs
dead 5-/il/O~