ETApplication #
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/permits
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: Z
Proposed t,or Business Name: -J/ 11112~
Applicant/Mortgage Co:
Mailing Address: - Zti"
City: Late: 4Z& Zip: p :2
Telephon . ( ) Other k ( _ ) _
Current Land Owner:
PIN:
State Road
Name of Subdivision:
,-Al Parcel:
State Road Name:
am. #-of Culp
Restaurant: # of employees---- I-_ # of seats Hours:
Directions: (please give concise, complete directions from Lillington, NC to the property)
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There is a $100.04 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 ONLf
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
re of Environmental Health Specialist Date ' y
SEPTIC 4/08
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