ETRta S-e do C ~LuL~s Application # l~ 7
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES, COMMERCIAL CHANGE OF
OWNERSHIP, FIRE DAMAGE, ETC
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date:
Applicant/Mortgage Co e,5 mv% -lo
e5 "7111 f_Ac~'q Mailing Address: a If
City: State: Zip:
Telephone: (V Other ( )
Current Land Owner: ~c Phone:
Propert Address: p .01 PIN: O 91 Parcel: O 0 / 21Z,
State Road ST e ad Name:
Name of Subdivision: Lot # (trnrPi~cab~c)
Directions: (please give concise, complete directions from Lil!i gton, NC to the property)
/ _ i _ 1 ~A . ✓1 . r
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
ature of Enviro ental Health Specialist Date
SEPTIC
1 1j_
4108
Your signature below certifies that all above information is corre t.
Signature of Owner, Authorized Agent or Applicant: G~c,~